"Sometimes Sandwiches Are Nice."

“But I like mayo,” the girl with the dreads and Peace Corps t-shirt lamented. They too were making sandwiches for dinner that night.

We were shopping for groceries in Nakumatt Mega City, a supermarket in Kisumu of industrial proportions where you can find pretty much everything from washing machines to peanut butter….but apparently not mayonnaise.

We had found our kinsmen.

Dave and I had just commented that we could count the number of Americans we had seen since arriving in Kenya on one hand. It was perhaps too generous of a pat on the back for traveling so far off the grid.

We had a hankering for sliced cheese. It had been a while.

And so we are coming to the end of our trip here. Our days of cooking channa and dal are numbered and we are trying to minimize the number of food items we buy, opting instead for quick fix “white bread” solutions. Though we have enjoyed our time here, we continue to yearn for home. I attribute part of this ailment to mefloquine, which wakes me up early in the morning after experiencing absurd dreams about parents of friends turning into zombies and loved ones dying strange deaths….not to mention the dreams of poisonous snakes crawling on our bed.

So the thought of a sandwich seemed comforting.

My mother, who has been known to put tabasco sauce in her ramen noodles “because otherwise it has no taste,” has also stated, on more than one occasion, that “sometimes, sandwiches are nice.”

Agreed. Sometimes sandwiches ARE nice.

*
These days I am desperately trying to hang on to and learn as much as possible….and trying in some way to give something back. I visited Dave’s clinic site last week and spent a morning rounding on patients in the ward with him. We saw several obtunded patients, all of whom had HIV. My general impression was that they either were in status epilepticus (ie a seizure that would not break), but of course we had no EEG to confirm, or they had severe cerebral edema from their toxo/tuberculoma/lymphoma or whatever space-occupying mass we could not diagnose because we couldn’t obtain toxo serologies for what they were worth, nor did we have a CT scanner or a neurosurgeon. Though these patients were unresponsive, they did have some focal neurologic signs- a unilateral positive Babinskis, unilateral clonus. I could have used a refresher on my neurology skills.

I could have used a great many things that day.

It was unclear to me who was actually rounding on these patients, but I soon found myself writing orders alone. Dave and I split up the ward.

There are days when there aren’t any doctors rounding on these patients. The nurses, who clearly are quite adept, handle everything on their own.

Not all of the patients were so sick. Some just had good old pelvic inflammatory disease/endometritis from their “septic criminal abortions.”

Fantastic.

It was by far one of the most depressing days I had had since arriving in Kenya.

On a brighter note, the lady who was failing her ARVs who I thought might have had a DVT came back feeling remarkably better. Her leg looked far less swollen and was not nearly as painful. I hardly think it was the Aspirin I had prescribed her...in retrospect, I wondered if she just had a plain old ruptured Baker’s cyst.

Tincture of time….what better place to test the efficacy of this panacea.

Her viral load was not back yet. I so desperately wanted to change her regimen, but yet again had my hands tied.
The rest of my time has been spent doing chart reviews and auditing and giving a few “CMEs” (continuing medical education lectures) here and there. (My audience is everyone from the other medical officer to the “office messanger/cleaner.”)
I have created a database of 4 “conditions” and looking at chart documentation and treatment plans for each. The most impressive of these is probably the diagnosis of upper respiratory tract infections, “URTIs,” for which many clinical officers indiscriminately prescribe antibiotics. So I am hoping to help them determine which patients merit antibiotics, which could probably use watchful waiting and which could use “further evaluation”- namely either a chest xray or sending sputa for AFB to rule out TB. It is hard in this land of tuberculosis, where every other person has a “cough”…or even back pain for that matter.

It is a bit hard for me to do this review, as my time here is so short. Moreover, the clinical officers here are amazing, but they are often limited by time. They each see as many as 30-40 patients a day in Rongo, largely because effective decentralization has not taken place yet. The process of “decentralizing” basically means rolling out ARVs to peripheral (more remote) sites and mentoring other clinicians in HIV management so that patients don’t have to travel so far. This also means that as more peripheral sites start running, fewer patients will be coming to the Rongo clinic, relieving some of the burden for the clinical officers and perhaps ensuring better care for those patients who do remain at the site. In the month that I have been here, Rongo has managed to open up three other sites.

The other part of the Rapid Results Initiative (RRI) is also to try to get as many HIV negative young men circumcised as possible. Most days the clinical officers who perform these surgeries stay as late as 9pm.

Primary education became compulsory in Kenya in 2002. Because it takes 6 years to create 1 doctor, and because there are about 300 medical students per class in the only 2 medical schools in the country, the government established this baccalaureate degree to create what we would probably call “mid-level providers” as an attempt to rapidly scale up health care delivery in areas where there are no doctors. The clinical officers don’t have as much basic science training and do not read “the literature” as much as we do. And to some extent they are less comfortable with uncertainty than we are, and less likely to stray far from their protocols. But they truly are masterful clinicians, far better than I in many ways.

The work is truly remarkable. I feel so fortunate to have witnessed and been part of a model of international health care delivery that is clearly doing so much good in the community it serves. They have taken the global health catch phrases “scale up” and “rolling out” to an entirely new level for me.

Everyone here works so hard.

It is inspiring. But I continue to be conflicted.