Archive for June, 2011
Arriving at the Nairobi airport on April 3 after 24 hours of flying, I was both excited and nervous about what my experience in Kenya would be. This was my first visit to sub-Saharan Africa. My experiences in Peace Corps Morocco certainly prepared me for traveling in a developing country, but I had no idea what to expect in Siaya and Ukwala.
We traveled to Kisumu via Kenya airlines and immediately drove to Siaya District Hospital where we had a tour of the facilities. While walking through the hallways, women came up to us with their pelvic ultrasound images asking us for advice and surgery. Even though it was a Monday (and not the GYN clinic day), we opened an impromptu clinic and started seeing women and booking them for surgeries. Then we continued on to a tour to Ukwala to see The Matibabu Clinic as well as the new Matibabu Hospital under construction.
Our first day at Siaya Hospital for the Tuesday GYN clinic started with a tall stack of charts and women waiting in the halls for us. We saw so many women I lost track of the number (perhaps 30-40?). We saw women with leiomyomata and uteri extending to the xiphoid as well as 4 women with advanced cervical cancer. Women do not receive regular cervical cancer screenings here due to lack of medical providers and education. It highlights the importance of cervical cancer screening, as we see so few advanced cervical cancer cases in the United States.
The following Tuesday, we again saw GYN patients in clinic. It’s amazing to me that they knew about our coming in advance and waiting for these particular clinic days to come to the hospital in hopes of having a surgery. There is only one trained obstetrician/gynecologist at the Siaya District Hospital. The other medical officers are essentially residents who teach themselves how to do cesarean deliveries and appendectomies so anyone who needs a hysterectomy or other specialized surgery has to wait for the one day a week that the surgeon operates. The overwhelming ratio of one gynecologist to an entire district of women highlights the need of the community for more surgeons.
We saw a woman with the complaint of copious vaginal discharge and bleeding and stated that a “white doctor” put something inside her vagina 2-3 years ago. Turns out she had not removed her pessary during all that time!
On our first OR day, we found out a laboring woman had died and had a perimortem cesarean delivery earlier that morning and the staff was still shaken from that event. We did an emergent cesarean delivery for a woman who had been laboring at home with a history of prior cesarean delivery in August 2010. She was taken to another hospital and turned away because of her bleeding and lack of blood products available. She was then brought to Siaya District Hospital for surgery and cesarean delivery was done for posterior uterine rupture. Her hemoglobin was 4.1 g/dL and she had large blood clots in her abdomen. Given the prolonged amount of time between uterine rupture and surgery, the infant did not survive. We also did an ovarian cystectomy for “Millicent” and noted significant tubal scarring which may have been causing her pelvic pain.
We had 2 more OR days while at Siaya District Hospital and performed some hysterectomies, myomectomies, and then ruptured a large tubo-ovarian abscess in an HIV positive woman.
I have to admit, I was completely unprepared for operating in Kenya. The availability of instruments, sutures, and staff is limited and many items that we consider single-use are used multiple times. It made me deeply appreciative of the equipment and OR staff that we have in the U.S.
I went to The Matibabu Clinic in Ukwala later in the week and spent time seeing patients. I had never seen a patient with malaria and I got the chance to see many! We went to a children’s club in the afternoon and talked about de-worming. We handed our albendazole to adults and children as well as USAID food/milk and vegetable seeds to the families.
I did two cervical cancer screening days with the community health workers and midwives and discussed cervical cancer education while I was volunteering with Matibabu, which was one of my favorite parts of my experience. In many ways, giving women education about their health and how to initiate change is an enormously empowering act, and it is a way that volunteers can profound impact the lives of many. There are only so many women that you can operate on or see in clinic but knowledge can be passed among women in a community indefinitely.
My experience in Kenya was one filled with gaining more clinical knowledge about OB/GYN in addition to learning about medical care in rural Kenya. The work I did there is small in comparison to the knowledge and experience that I gained from the patients I saw and the health workers I met. I saw advanced disease that is luckily rare in the U.S. due to our medical system and patients’ knowledge about their health, and it highlights the privilege we have in taking care of our patients here. I am grateful for the opportunity to volunteer with a community driven health center like Matibabu/Tiba Foundation during my residency training in OB/GYN, and it has given new purpose to my work here as well as my future goals to volunteer internationally.
Upon arrival to Clinica Esperanza, I was impressed with how new and fully stocked the clinic was. I have worked at clinics in Guatemala, Mexico, and Ecuador, and this was by far the most modern and comfortable. There were ample gloves, hand gel, towels, gowns, medications and medical supplies, which led to a safe practicing environment for both the patients and practitioners.
The patient population was made up mostly of the local colonies of the poor immigrants who settled on the islands after the major Honduras hurricanes. These “towns” are called “La Colonias.” The average income is about $3,200 per family/year and they have very little access to healthcare. There is one public hospital, at which I had the opportunity to work, and it has virtually no financial support. There is no drinking water, toilet paper, or soap, and the wards are made up of 8-10 people in a room of beds without curtains. It only costs the patients fifty cents per visit, but they may end up waiting all day without ever seeing the doctor. Therefore, there is a huge local support for Clinica Esperanza.
My experience was mostly based in the clinic. They have a new Labor and Delivery (L&D) ward, which is still awaiting licensing, so it is not yet open. I worked from 8 am – 2 pm daily, seeing both routine gyn and obstetric patients, but also the more sub-specialized Ob/Gyn patients. I managed many teen pregnancies, gestational diabetes, pregnancies complicated by malaria, multiple missed abortions and outpatient management of pyelonephritis in pregnancy. I also saw several patients with secondary amenorrhea, in which I had to decide if a certain lab, which would I would normally reflexively order in the US, was worth the cost of one month’s salary. I had to rely on my history and physical to make the diagnoses and could only use labs as supplementary.
There is a strong need for women’s healthcare and advocacy in Honduras and I hope I was able to educate both the patients and the permanent clinic employees on how to better address these issues. I plan on working from the US to help involve a clinic based Ob/Gyn attending for more difficult cases and to help organize the infrastructure of the L&D. I plan on returning next March during my elective time to continue these goals. It was overall a great experience and one I would recommend to any second year or above Ob/Gyn resident.
My last week of Port Antonio Hospital was a slow day on the ward as well as clinic, having only 2 patients to be seen in clinic which was a contrast to the previous week which had us working with no breaks up until the moment we left. One was a young girl I diagnosed with inguinal hernia and referred to the Surgeon down the hall and the other was a 7 month old baby who was unable to make it to the appointment but had been referred for evaluation for achondroplasia. I listened to the social worker who was there representing the mother and she explained how the mother had come several weeks to see a pediatrician but that the weeks she had come, there were no pediatricians available and today both were unable to make it due to a complicated social situation. The baby was apparently disproportionate in size with short extremities and a description that fit but had not been formally seen or diagnosed with a genetic condition. Of note, there are also no medical geneticists on the island in addition to other pediatric subspecialties.
On the way back from Port Antonio, the Ministry of Health employee who was kind enough to drive me back the two hours back to the resort explained to me all of the different type of plants and fruit trees lining the road ranging from banana trees, breadfruit trees, mango trees, and ackee trees. I expressed my interest in trying ackee and saltfish which is a national Jamaican dish. He stated the dish was delicious with breadfruit, but he warned me that ackee that is picked too early can be poisonous. Other people who call this dish the Jamaican Rundown, told me that one has to be careful about who you buy your ackee from but that the dish is very delicious. I asked one of the doctors at Annotto Bay about this, and she told me there was recently an outbreak in ackee poisonings this past year with a spike in the number of cases. Due to ingestion of ackee that has not fully matured, the toxin Hypoglycin will lead to hypoglycemia and symptoms of vomiting, stomach cramps, and diarrhea and in severe rare cases, coma or death. I found this useful information to know and has somewhat dampened my curiosity in trying this fruit.
The next two weeks at Port Maria were busy and a week after the departure of my wonderful colleague Dr. Hack, I found myself incredibly busy seeing 26 patients in clinic one day from 9 AM to 4PM. I realized how just like at the end of any rotation, you start feeling comfortable with how things are run right when it’s about time to leave. One of my more complicated cases was a preadolescent boy diagnosed several months ago with HIV but who was not aware about his diagnosis. He came in with 3 weeks of cough and a rash which looked like tinea versicolor. I obtained a chest xray which revealed an infiltrate, keeping in mind that the mother stated he had been on several weeks of an antibiotic which finished a week ago, but now was not on any medications and that his first appointment to discuss his condition was next month. None of this information was located in my paper chart and without any previous labs or other information about which antibiotic he previously was on, I discussed a plan of care with the ER doctor who knew him well and sent him to the A&E for further work-up including a CBC, viral load, CD4 count and initiation of antibiotics.
The rest of my clinic visits at Port Maria in the last two weeks were the same ranging from well checks, scabies, deworming, a variety of skin rashes and referrals to other hospitals for conditions requiring surgical intervention. Three medications that I felt helpful to know were Tropovite Vitamin Drops which contain Vitamin D, Hemafed which contains iron, and Rid Cream for scabies and lice. I would ask to peruse the pharmacy counters before clinic on days I had time because knowing which medications were available in the pharmacy is invaluable to avoid having families paying out of pocket for medications at private pharmacies when alternatives can be easily picked up at no cost here.
Another thing I take for granted in the states are scheduled appointments. I find it hard to take breaks knowing that patients arrive at 9 or 10 in the morning for an appointment. Once a parent even pretended his son was another patient so that he could be seen earlier and I only discovered this after the parent of the actual child asked why they had not been seen yet. Due to this, I have made it a habit of asking the parent the child’s birthdate before starting the visit. I’ve also gotten used to adults randomly walking into my room, even in the middle of a child well check, and start telling me their ailments. I always have to gently cut them off and explain to them that the family practitioner across the hall can aid them and that they have to wait for their turn.
Here are a couple of photos of 2 adorable children seen in the clinic: (written consent obtained from parents).