The Matibabu Clinic

5/9/12

Posted by Jenna Kubat, MD (a third year Ob/Gyn resident from Kaiser Permanente San Francisco) serving  a global health elective in Kenya with The Tiba Foundation/The Matibabu Foundation.

From the moment I stepped off of the plane, I was greeted with warm smiles and friendly curiosity. “Is this your first time to Kenya? What are you doing here?” These were frequent questions and I often answered timidly, not sure how the locals would respond. All over Africa, there were missionaries and organizations present to “help” the people living there. The signs of poverty were many: dirt roads, mud huts, shoes with holes in them, if shoes at all. Yet, here were people who appeared happy and industrious and I wasn’t really sure what my role was and even more, did they really need my help? “I’m here to do work with the Matibabu clinic and perform surgery,” I would say. This would strike up lots of conversation and usually a story about how the clinic had helped a family member or themselves. I could tell we were in the right place working with the right people.

The first week of my rotation was spent working with the clinical officer at Matibabu clinic in Ukwala. The clinical officer, Dorah, was an amazing woman and knew SOOOOO much. She essentially had the training of an internist after 1 year and was expected to treat anything that walked in the door.  This could be as simple as a cough or cold, to a fresh wound or chronic infection. She saw young, old, men, women with all problems and she had it down. Her job was to provide as much care as she could in the rural setting and identify when the patients needed a specialist, which sometimes they did. Then she would send them off to Siaya, Kisumu or Nairobi. Now I will admit, my contribution was not all that great, since she saw a lot of children, malaria and diarrhea, none of which I have much experience with, but I learned a ton about common infectious diseases such as malaria. I also learned I better use my mosquito net and take my prophylaxis. During this week, we also spent time working at a maternal child health clinic. Many women in the rural areas were still birthing their babies at home, but there was a strong push to have more women delivering in the hospital (which the government covered). However, one thing that really stood in the way of this was accurate dating and consistent prenatal care. Women often showed up well into their 2^nd or 3^rd trimester for their first prenatal visit. Ultrasound facilities were limited, so most women were dated by the LMP (last menstrual period), which could be highly inaccurate. Once women had an EDD (estimated date of delivery), they would often move or stay with family members closer to the medical facilities. But as you can imagine, these due dates could be as much as 3-6 weeks off and there was no telling whether they’d make it to the hospital in time if they weren’t nearby. So part of our contribution was providing ultrasounds for dating. This could help confirm due dates or re-date them to make their future travels a bit easier. Every woman also received prenatal testing at this visit (Blood type, HIV testing, etc).

During this week in the clinic, we also spent a day doing community visits. We went with a community health worker to people’s homes who were infected with HIV. These individuals ranged in severity of their illness from mobile and relatively healthy, to bed bound and unable to leave their home. One individual who really stuck out was a woman named Helen. She was HIV positive and lived in a small mud hut in rural Ukwala. For the past year, she had been completely bed bound because she had developed bilateral lower extremity paralysis. She had 2 small children, but was unable to care for them because she could not get out of bed. She was advised to have an MRI to evaluate whether or not she had a spinal lesion, but she couldn’t afford it, so didn’t have it. She complained that she had been having increasing abdominal distension as well and was unable to tell when she had to urinate but it would sometimes just leak out. As we walked into her hut, the whole place was permeated with the smell of stale urine. Because she couldn’t get up, she spent all day in bed, went to the bathroom in bed, etc. She was advised to use a foley catheter, but it was too uncomfortable, so she decided to just remove it. Her bladder was above her belly button. We struggled with how to help her. We knew that she needed imaging, but the least we could do was offer her a foley catheter. We explained the need, but she didn’t seem too interested. In addition, we weren’t really sure how much it would help. We could empty her bladder, but that may put her at higher risk for a urinary tract infection and sepsis, which could ultimately lead to her demise. We were stuck with wanting to help, but not really knowing how. This is an example of how simple clinical decisions that I make every day (place a foley, order an MRI) can become much more difficult when the conditions are different. It really made me rethink all of those “simple” decisions.

During the next week, we performed surgeries at Siaya District Hospital, a basic, well-functioning, government-run facility in rural Kenya. There were 2 operating rooms, connected by an open doorway. No air conditioning was present, instead the rooms were hot with fans that sometimes worked. The facilities were clean, but the concept of sterility was slightly different. Resources were minimal: bovie pads donated by previous clinicians were reused and taped to each individual. Bovies, which are regularly thrown away in the United States after one use, were re-sterilized and used until they were cracked down the middle. Sutures used were those that were left over from previous groups. Cloth gowns, masks and surgical hats were used. Electricity was present, but frequently went out or there often weren’t enough plugs to power all of the machines we needed to do a surgery. Despite this, we were able to operate on patients and provide safe and adequate care.

The operations we performed were anything from a tubal ligation to removing a 12.5 pound uterus filled with fibroids. Each operation was challenging in one way or another. I learned through this experience exactly what I needed right down to the number of suture and what type, for each operation. Take for example, the hysterectomy we performed using a cesarean section tray and heany clamps. All of the major laparotomy sets were in sterile processing, as they were not used to performing so many operations, so they asked, “Can you use a cesarean section tray?” Now if I had been in the U.S., I never would have done it, but I knew I had no other choice (and of course, the patient was already asleep, because they didn’t figure it out until then). So I looked through the set and it had retractors, Kelly clamps, cochers, pickups and with our supplemental heany clamps, our set was complete. We performed several hysterectomies with the cesarean tray (not by choice) but soon I realized what tools I truly needed. In a similar fashion, I learned a lot about the number of suture needed for each case and how to run all of the electrical equipment used. Before every surgery, I opened exactly what was needed suture wise, no more because you would never want to waste it. I also hooked up every bovie machine and made sure all the pieces were functioning. These were all things I took for granted when operating, but soon learned about their importance. 

In addition to all of the logistical knowledge I acquired, I also learned a lot about gynecologic disease in Kenya. Many of the women we operated on had evidence of previous pelvic infections. The layers of adhesions we encountered were impressive leading me to believe many women have longstanding PID (pelvic inflammatory disease) that never receives treatment. And just like women in the U.S. who have a history of PID, these women had trouble conceiving. The unfortunate thing is that for many with tubal disease, IVF was not ever an option. So I can only imagine how these women could be ostracized because they would never be able to conceive. Similarly, the incidence of fibroids was high. We took out 2 uteri that weighed over 2.5 kg as well as one that weighed 5.6kg. These women had been suffering for years with heavy bleeding or abdominal pressure and distension leading some to wonder if they were pregnant. The look on their faces after we were able to remove their uterus was indescribable. It was life-changing for them and no local doctor would ever touch them because the operation was too risky. But luckily, their procedures went smoothly and were without complication.

My experience in Kenya was indescribable and the impact it will have on my future practice of medicine is yet to be determined, but I know it has changed. I met people with such spirit and such gratitude that I knew my work was worth it and that I had made a few people’s lives better. It’s difficult to express all of the emotions that run through one’s mind after an experience like this, but as I continue to process all of the emotions, I will continue to reflect on everything I’ve learned in the hopes of one day returning to Kenya or another part of the world to share in the knowledge I have obtained.

Leaving Matibabu

Posted by Lisa Ryujin, MD (a fourth year Ob/Gyn resident from Kaiser Permanente Oakland serving  a global health elective in Kenya with The Tiba Foundation/The Matibabu Foundation).

Returning to Matibabu was a wonderful experience but totally different than my previous visit. The last time I was here, I came alone, worked in the community, with traditional birth attendants, in the clinics and with the government to improve education and public health. I struggled to understand the health care system and worked with the local clinical officers to figure out ways that we could more effectively triage and bring people to services.

This trip, because I came with an attending, Dr. Miller, we were the health care services. We were meant to do a month of surgery, but due to the nursing strike here in Kenya, we went to where I spent time working in the community my last visit. It was familiar, I knew the people and the places, but it was totally different because they brought us to people’s homes for evaluation. We went to the clinics to review ultrasound skills. We put our hands on people.

The Matibabu staff is truly amazing, two years have passed since my last visit but they are still tirelessly working. The Nzoia clinic has expanded to more than double its original size, a new hospital has been built and the community health workers seem more dedicated than ever. They are an inspiration.

When the nurses strike ended and we were able to go to Siaya, I was so grateful that we had the time in the rural clinics (Ukwala). We had a better understanding for how much it took to get to Siaya (The clinic visit, the triage, arranging funds for transport, the actual road in a crowded matatu and the emotional stress for these women to be away from their families as the primary care givers). We evaluated them again and counseled them regarding their condition and possible treatments, we took them to the operating room, and in most cases, did the case under regional anesthesia (the patient is awake but numb from the breast down), and they recover in the post operative wards together, sometimes two patients to a bed. Despite these conditions, our patients did exceptionally well, we were met with smiles and thanks in the mornings and Pasqaliah, the head nurse, fought with great tenacity to make sure that the patients were not over charged because Matibabu was providing a free surgical camp.

The operating room staff in Siaya also commanded a lot of respect. Our anesthetists were brilliant, and despite the conditions, gave us amazing regional blocks. Although I am very sensitive to making sure the patient is comfortable during surgery (especially if they are still awake!) I frequently leaned over the curtain to check and they would be sound asleep! The scrub nurses were exceptional, and although we did not have all our regular instruments available, they were ready and willing to take part in the process of being creative and working with what we had. And, the nurse runners/circulators, they always have a hard job, trying to pull suture and get more sponges and instruments, but with the frequent black outs, they also had to frequently reset our electrocaudery and our lights. They also had the tedious job of pouring water over our hands so that we could scrub if the water was no longer running in the hospital, and you can also imagine, it was someone’s job to fetch the water! They all stepped up and made an extraordinary team!

Dr. Miller and I would have dinner (with a Tusker) every night and de-brief, what went well, what could we do better, how would we approach the next day’s cases. The work was endless. But he said something that I hope will stick with me until the end of my career, “no other field in the world, except medicine, has these kind of responsibilities but also, these kinds of rewards.” I think back to the woman that had the ruptured appendix, another woman we operated on that had a ruptured ectopic, and I can say without hesitation, that they would not have survived if they had not gone to the operating room. I can think of countless other patients who had long-standing problems that I hope will have been remedied by the procedures we did. But I especially wish that there will never be a time when I don’t recognize the great privilege it is to be able to practice medicine, to be involved in patient’s lives when they are most vulnerable and to provide counseling to aid in patient’s feelings of empowerment over their own lives. I feel so incredibly lucky and can’t wait until my next trip!

Miracles

Posted by Lisa Ryujin, MD (a fourth year Ob/Gyn resident from Kaiser Permanente Oakland currently serving  a global health elective in Kenya with The Tiba Foundation/The Matibabu Foundation).

I remember that it was in Africa that I started to believe in miracles. The patients came to the hospital so sick, and when you evaluated them, you think in your head, I hope that this woman doesn’t pass away before we have the opportunity to take her to the operating room. After being in the operating room for 3 days, doing gyn cases, the chief of the hospital asked us to evaluate a woman who just came in with an acute abdomen (rigid on exam with gaurding). She said that the pain started a week ago, sudden in onset, and she was taken to local medicine men, who claimed she had been cursed, and then removed ‘glass’ from her abdomen, she had not improved after this treatment, and they brought her to the hospital as a last resort. We were asked to take her back to surgery. We looked at her ultrasound, and were not convinced that the mass in her abdomen was from her ovaries. We decided to take her to the operating room because she looked so sick and there wasn’t another surgeon who was available to take her back. When we opened the abdomen, the whole abdomen was filled with bowel contents. She had a ruptured appendix that her body was trying to wall off. By some miracle, there was a visiting general surgeon who happened to stop by the operating room to help us to run the adherent bowel and fix the ruptured appendix. We opened her from sternum to pelvis, and when she woke up, I expected her to be writhing in pain (for these big open incisions, we would put our patients on a PCA to deliver around the clock narcotics), to my surprise, she just smiled and said that she felt so much better. I could only imagine how much pain she had been in prior to going to the operating room. Every morning when I go to see her in the hospital wards, I am amazed at how well she is recovering. My initial thoughts were, I hope that she makes it through the night, but the scrub techs all reassured me that she would, they had seen much worse, and they were confident that she would pull through. Here we are, almost a week later, and she is eating, sitting up, walking, and doesn’t have any residual effect of the surgery or the ruptured appendix except her scar, a battle wound that reminds her how lucky she was.

Matibabu Experience, February 2012

Posted by Anne Goh, MD (a third year Internal  resident from Kaiser Permanente San Francisco while serving  a global health elective in Kenya with The Tiba Foundation/The Matibabu Foundation).

I spent 14 days including travel time from San Francisco to Ukwala, Kenya in February 2012 with the Matibabu Foundation as part of my global health elective. Even though the time was short, I am so happy I took this opportunity to experience healthcare in a resource limited setting in Kenya before  the end of my Internal Medicine Residency training.

Coming back to do a second residency in Medicine in the United States after a long spell away in research and volunteering, I was drawn to the tremendous advances made in the world of HIV medicine as well as in infectious diseases. Working in the HIV module as part of my ambulatory care experience for the past 2-3 years in San Francisco, my interest in healthcare disparities while working on my Public Health degree in Berkeley, as well as my previous experience working in a refugee camp hospital in Thailand and Burma, made me choose Matibabu Foundation as the location for my global health elective.  I was keen to experience healthcare delivery in a developing country especially in a region which has the highest HIV/AIDS and malaria as well as tuberculosis prevalence in Kenya.

Matibabu Foundation’s work is based in Ugenya district in Western Kenya. It runs a community clinic at Nzaio and the newly opened Matibabu Hospital in Ukwala. It also manages and supports the Comprehensive Care Centers for HIV/AIDS in Ugenya district with its main clinic at the Ukwala Health Center (Ministry of Health run clinic). The foundation manages about 700 community health workers who are volunteers from the community, who provide education about sanitation, water, preventive health, bednets, nutritional support and who alerts the foundation of individuals who may need more assistance.

This is my first trip to Sub-Saharan Africa. I was privileged enough to have one of my friends and Kaiser San Francisco Hospitalist, Dr. Melody Choong share on this journey as my supervising attending. We stayed at the Camunya Hotel in Ugunja which was 13.5 km from Ukwala, which took us about 30-45 minutes by car. The road is unpaved with many pot-holes, with a narrow bridge across Nzaio River. We spent a day at each of the facilities seeing patients. The clinical officers helped us out tremendously, providing translation for our patients who only spoke in Swahilli or Luo. It was amazing to see how great their diagnostic skills are, having to rely on history as well as physical exam solely to make a diagnosis and modifying treatment plans according to what medications are available or affordable for the patients.

We were warmly welcomed by the patients and the clinical officers at the Comprehensive Care Center for HIV/AIDS. Patients, the majority were women and children, sit patiently waiting their turn to be seen. Part of the PEPFAR/ICAP programs, HIV care including consultation, lab tests and ARV as well as TB medications are provided free of charge. Most of the patients are given monthly supplies of their ARVs and they are followed closely by the center. It was disheartening to see that many men with HIV remain untreated because of a lack of understanding and acceptance of the disease and treatment. There were also cases of women who were prohibited by their husbands to seek treatment. Because of the high rate of malaria in this region, more than half of the patients who come for their routine follow-up also get tested for malaria if they have any symptoms suspicious for malaria. We also diagnosed several cases of possible tuberculosis during our one day at the clinic.

We spent a morning with one of the community health workers, who took us on a bodaboda (there were four of us on 1 motorcycle) to visit the nearby villages. We walked to visit several homes. What struck me the most during our walk was the many empty houses where entire families have perished with the HIV/AIDS epidemic. Some homes which we visited, the children including babies were left on their own in front of their houses while the mothers traveled to carry water. We learned that the Luo people look after their extended families: there was an elderly woman who was unable to walk because of disabling arthritis and back problems, whose children are gone but the rest of the village helps out by carrying water for her, providing her with food and even cigarettes! We also met an elderly man with rheumatoid arthritis and a previous stroke who was given a wheelchair by Matibabu. His son will be one of the first from the village to enter University. He makes bricks from mud with his father to save money for school and at the same time is working on a chicken egg farm business to help support his family while he is away at school. His goal is to study economics and use it to help his village develop and improve the lives of everyone here. It was inspirational to see how Matibabu’s outreach is influential in changing the lives of an individual, family and community.

I’m going to write about several interesting cases I saw during my time in Ukwala which highlights the needs and challenges facing the healthcare teams here.

A 25-year old man who was semi-comatose, brought in on the back of a motorcycle taxi (bodaboda) sandwiched by his brother and the driver, h/o rapidly progressing deterioration in his mental status, headaches and fevers, several months weight loss and possible history of HIV not on treatment. He looked severely emaciated with bitemporal wasting, was not able to follow commands, not able to verbalize, eyes opened spontaneously, some neck stiffness, no other focal neurological signs. The working diagnosis was meningitis, possible cryptococcal meningitis. He was ruled out for malaria. The dilemma was not being able to examine the CSF as the lab was not equipped, no CT scan for neuroimaging to rule out a mass lesion, not being able to confirm his HIV status as there was a HIV diagnostic test crisis in Kenya (with recall of one of the rapid HIV test kits), fluconazole IV not available at Matibabu Hospital, amphotericin B unavailable, the closest facility with this medicine is at Siaya Hospital which is at least 1.5 to 2 hours away and the prohibitive cost of this medicine. He was given ceftriaxone IV and transferred to Ukwala Health Center where he expired after several hours.

A 17-year old woman presented with shortness of breath, fever, chest pain typical for pericarditis and arthralgias. She had a sore throat 2 weeks ago. On exam, she had a temp of 102F, tachycardia, tachypneic, JVP not elevated, MR and AR murmurs all over precordium radiating to her axilla and back/scapula areas with mild ankle edema. After looking up quickly in Pocket Medicine, we diagnosed her with acute rheumatic fever. Having so much reliance on our lab/radiology/ ECG/Echo support, we were suddenly at a loss as to what to do next to help confirm our suspicion since Matibabu hospital (or the rest of Ukwala) does not have access to X-ray, ECG machine or a rapid strep test or echocardiography (electricity is still unavailable, only 1-2 hours each day). We settled on empirically treating her with aspirin and penicillin, low dose lasix and have her return to the clinic in 2 days for follow-up.

The highlight of my trip is the warmness, generosity and kindness of all the people we came in contact with in Kenya. The smiles on their faces, the friendly greetings as well as the love and concern for others touched me tremendously during my time here. It is truly remarkable to see how Matibabu has changed so many individual lives, touched families and empowered communities in the Ugenya district of Western Kenya, through its partnership with the indigenous communities, Kenya Ministry of Health (local clinic and district hospitals), different sponsorships/programs from the United States (PEPFAR, ICAP). This goes way beyond the basic delivery of healthcare. It provides a foundation for individual and organizational sustainability through its wide-ranging community education and support programs like school outreach, sewing, beading and computing classes for the youth, many different agricultural programs and many other projects and activities.

The 4-person bodaboda

Arrival in Kenya!

3/19/12

Posted by Lisa Ryujin, MD (a fourth year Ob/Gyn resident from Kaiser Permanente Oakland serving  a global health elective in Kenya with The Tiba Foundation/The Matibabu Foundation).

It was so great to be welcomed back to Matibabu and Ukwala with such affection and joy. It was beautiful to see all the friends that I have been staying in contact with through facebook and email, and to see how wonderful things have been progressing. The new hospital is built! The Nzoia clinic has been developed from the 1 room clinic that I saw 2 years ago to a bustling HIV counseling center and treatment center! I even was able to participate in some educational support groups for HIV + mothers.

I was lucky enough to go into the Northern Ukwala community with one of the most incredible community health workers. He told me his story as we were walking, door to door, to find his patients. He was a accountant in Nairobi and fell ill, when he went to the hospital, he was told he was HIV+ and given drugs. He said that he knew he was O+ and that he wondered why he was being given drugs, but took them. Later, he had to go back because he had TB, during this hospitalization, he was counseled thoroughly that HIV was the cause of AIDs, which he had heard of. He began to understand that he was infected, and after his treatment, came home to Ukwala to sort things out. During this visit, he found that there were local government programs that would provide his medications for free and so he was going to be treated here at home. During this time, he returned to the community, and began to recognize the signs and symptoms of HIV, and began to encourage them to get tested and to know their status, and thus, the community health workers were born. He continues now, 22 years later, going door to door and helping patients to access health care.

The first patient home that he took us to, we had to arrive by motorbike along windy and unmarked dirt roads. It reminded me of working on the reservation, only a local could find their way to these houses. We were greeted by many people, sitting along the side of the house, in the front of the house, all appearing as if they were waiting…for us? For an educational session? He walked in, although he too seemed puzzled. As we made our way inside, shaking hands and exchanging greeting along the way, we found that the man we had come to visit had passed away last night, and that these friendly faces, all waiting, were in fact mourning. It was incredibly sobering, and as we tried to express our condolences, I could see that he was affected. What if he had come last night instead of today, could anything have been done? These questions, you have to ask yourself as a health care worker, and just as you saw the sorrow on his face, he pushed it aside and proceeded to lead us to the next house, the next patient that needed to be checked on, and the next family that needed help. He called the clinic to let them know that this patient had passed away, and also told the family that after his work was done, he would return. I knew he would.

We did this for the entire day, we visited sick patients, occasionally finding that we could help, sometimes able to offer suggestions, many times asking them to go to clinic and get further treatment. His dedication and persistence was admirable, and this is what truly transforms health care. I think that the community health workers are the secret weapon to combat disease in these rural communities, but how many men and women do you meet with this sort of dedication?

Although we were meant to come to Kenya to operate at the Siaya district hospital, the nurses have been striking and we have found ourselves in this strange limbo. But I couldn’t have imagined a better use of our time, last week we taught the nurses to enhance their ultrasound skills, identifying multiple gestations, abnormal placentation and malposition. We assisted in deliveries, talked through difficult gyn cases with the clinical officers, and now we are able to go to offer a door to door service that gives us an idea of what patients go through to even make it to the doors of the clinic.

We are suppose to move to Siaya at the end of the week to start operating on the patients that we screened last week, but I am also happy staying here, seeing how it all fits together, how the team effort produces better patient care, and just being a part of it. All I can say, is that this month hass only just begun, but that I feel grateful to be working alongside with such wonderful and dedicated clinicians. It gives me hope for the future of medicine, here and at home.