Wednesday, January 28, 2009

Memorable Quotes

"Just suck on it and spit" - Anonymous describing how to eat sugar cane.

"When I retire [for the third time] I'm going to become a missionary and convert the fundamentalists to Christianity." --Joe Mamlin

A Few Loose Ends

Wanted to take a minute and post what will likely be the last update for this trip.  I'm flying out tomorrow evening and will likely be packing most of the afternoon.

The next two photos are immediately after I adopted the piece of thorn that I'm bringing home from Baringo two weekends ago. As you can see I had several highly-trained medical professionals working on me, so I was definitely in good hands.  The second picture shows just how many bystanders a wounded white man can attract.  Keep in mind, this is on an island in the middle of a lake with no electricity or running water. Pretty impressive huh?

 
I surely hope that no one is offended by this next photo, it's definitely the current winner for my favorite matatu of all time.  I love it because it's completely nonsensical for everyone here, and they must have just liked the words.  For those that don't know - matatus are the primary mode of transport between towns and even within town for most kenyans.  They are small Nissans that are piloted by loosely organized hooligans regulated to 14 persons, but will frequently hit at least 18.  The reason for the increased passengers is that every one over 14 is pure profit for the driver.  Nearly all of the matatus are decorated, in addition to the required yellow stripe.  Common themes include - "Jesus is Lord", "Gunners" (for Arsenal, the favorite soccer team of nearly all of Kenya), or various American or Tanzanian hip-hop stars. There isn't all that much Engrish here, but I think that this would make the Japanese proud.


 
Well, there's always more to do with the radiology department in Kenya, so I'll summarize what I think our accomplishments have been: We have a system that captures nearly 200 chest x-rays/month that will provide the basis for at least one validation study.  The image capture has been working smoothly for about two years.  This whole trip has focused on reporting, and to that end I've built a form that can be used to "dictate" a normal exam with just one click.  Abnormal exams take between 3-4 clicks and have an optional free-text field.  The report form also has easy links that open comparisons with a touch of a button.  Everything is compiled automatically by the system into a .pdf report that is printed by the secretary in teh department. The system also sports dynamically updating "worklists" or queues that allow folks to quickly identify the exams that need to be read, or printed.  I've done all of the cheerleading that I can, and now the success of the project is in the hands of my Kenyan counterparts.  
With that, I'll sign off and see you all back in the states soon!!  E-Kohli will likely live on (I have to keep up with Heather), but will take a backseat to some much-needed PS3 gaming and planning for the next adventure - Baltimore, MD in March.  Stay Tuned!!

Sunday, January 25, 2009

Spree

No picture for this post, mainly because I didn't want to have my camera stolen.  After two previous trips to Kenya, I finally broke down and went out to a club here in Eldoret called Spree.  Turns out that clubs in Kenya are just about like clubs in the states with a few subtle differences a summary is below:


Similarities:

  1. About 3:1 ratio of boys chasing scantly clad women
  2. Abundant alcoholic beverages
  3. A television was never out of eyesight
Differences:
  1. The televisions play soccer 24/7 - Kenyans are big fans of the English premier league
  2. Not as much smoke - cigarettes are expensive
  3. Nearly all of the scantly clad women in similarity #1 were "working women"
  4. The music and lights frequently went out for a few moments before someone started the generator
I went with Martin, and another Kenyan doctari friend of his as well as Rachel Vreeman.  We ran into one of the IU house drivers (Javan?) there as well.  Javan seemed to know nearly all the girls in the place, and thought it was pretty funny to have the working girls pay attention to me.  One girl put her arms around me and kissed my cheek saying "I love you so much".  I was just happy that she didn't vomit on me as she was W-A-S-T-E-D.  Of course, I was one of only 3 mzungu in the place so there was a lot of staring.  Rachel got even more attention, including from a boy who attempted to kiss her without invitation - we decided that it was time to go after that.  All-in-all a new experience that I won't soon forget.  I had just washed my jeans and didn't think to change out of them before going out so I had to do laundry again today :-(

Saturday, January 24, 2009

My New Ride

Just kidding!  In all seriousness, one of the things that is markedly different during this trip is the arrival of the cheap 250cc chinese motorcycle which has instantly become ubiquitous.  The quaint boda-bodas (bike taxis) have been replaced by loud, daredevil motorcycle taxis.  The whole trend is disturbing, not only from a resource utilization standpoing, but as Brett pointed out - what are Kenyans doing with all of the time that's being saved with motorcycles?  

The bird walk today was pretty cool, we drove out of town until we came across a little "road" that went off to the left.  We proceeded down the cow path to a tiny farm close to the Kaptagat forest.  We walked around and saw many pretty sunbirds, and a spectacular pair of Hartlaub's Turacos.  On the way back to the house we pulled off another "road" and found a family of colobus monkies which were also great to see.  All of this was within 10 km of Eldoret!

Heather, I'm sorry to disappoint, but I was trying to pack light for this trip. I've actually sold my big lens, so that I can get a better version in July, so it wouldn't have been worth lugging that big monster here anyway.  Next time :-)

Friday, January 23, 2009

A Chill Evening

Tonight I was treated to a great meal with great company.  Betsy and Tal Bosin 'imported' a stick of pepperoni from the states and used it to make pizza tonight.  For those of you who don't know, pizza is one of the things that is impossible for Kenyans to understand and make well, it apparently takes the mzungu touch.  For my contribution to dinner I made a pan of my famous brownies.

I also made a Berne connection tonight - it's impossible to escape them.  Dr. Edward Leichty arrived today, he's a neonatologist from Riley and is working in Busia (Kelvin's home town) with some nurse midwives to improve obstetric care as a part of a global study that has two sites in Africa, one in Pakistan, at least one in South America and a few others that I can't remember right now.  The project is funded by the NIH and Gates Foundation (more info here).

I'm also really excited because tomorrow morning I get to go on a bird walk with Joe Mamlin, which is one of the most special treats that one can hope to have in Kenya.  Will post an update tomorrow, although the bird pics are relatively crappy with my point-and-shoot.

Hope everything is well in the states.  Send me an e-mail if you have a spare minute :-)

Thursday, January 22, 2009

Birds

Sometimes it's hard to feel like I'm getting anything accomplished because there is so much to do here, so I thought I'd wrap up some of the major things that have been accomplished: We now have a form for reporting chest x-rays that takes very little time to enter and we've developed a printable .pdf report that can be used to return with the film for improved communication, so people shouldn't have to write or type anything.  Now all we left is the easy part - to entice our Kenyan colleagues to read the films. 
Someone requested some bird pics so here is your diversion for the day!
These are weavers begging at the Lake Baringo Island Camp last weekend.

 The ugliest birds ever - Maribou Stork  (Masai Mara - last trip)

Go-away bird (Masai Mara - last trip)

 
Wattled Plover (Masai Mara - last trip)
Kenyan Starlings are so beautiful.

Tuesday, January 20, 2009

Kogelo

It should be no surprise that many of the people at IU house are big Obama fans.  So, when a few people started talking about a pilgramige to Kogelo, Kenya for the inauguration celebration, I figured - what the hell.  So, after the 3 hour car ride packed with seven people (3rd row seats *rock*) that took 5 hours due to a few wrong turns and a stop for lunch, (where we almost bought a life-size Barak cutout) we got to Kogelo.  



The craziest thing about the trip was just how excited all of Kenya is about Obama.  As we got closer and closer to Kogelo anyone who saw all of the white folks in a car started screaming Obama, Obama.  You can hardly turn around without seeing an object with Barak's face (see tire cover).   Today the entire newspaper was occupied, and everyone at the hospital was wearing buttons and T-shirts and talking about the inaguration.  As I write this, the whole town is going crazy partying, and every television station is rebroadcasting CNN coverage of the inaguration.


Back to Kogelo - There were about 200 people milling about dancing and celebrating on the grounds of the school named after the senator.  Of course, like everywhere in Kenya, there were the obligatory curio shops lining the courtyard as well.




They even had this larger-than-life embodiment of Sarah Obama (Barak's paternal grandmother) complete with fake breasts and a booty.



We bought some cheap T-shirts for $2.00 to commemorate the experience. The best parts are in the videos that people shot, which I'll share when I get home.


This school boy was happy to dance for the camera.


There were a few other groups of wazungu milling about as well as quite a few people from the news media.  We were able to walk to Sarah Obama's house and see it from the outside as well as wandering around the secondary (high) school.  We took a break to have some sugar cane before the ride home, which was much faster.  It was definitely an adventure that I won't soon forget.

Monday, January 19, 2009

Back Pain Update

I forgot one of the most important things about the back pain patient - she recovered walking function after surgery!!!

Baringo and Bogoria

This weekend we (Left to right: Marissa, Chris, Me, Brett) headed down into the Rift Valley to Lake Baringo Island Camp (Blue placemark).

View Larger Map

Island camp was built in the 70s, on land that is leased from the tribe that lives on the island.  The camp only takes up a small portion of the land mass at the southern tip.  It's a tented camp with nearly all of the "rooms" facing east, which means that you can watch the sunrise from your bed (although it was raining Saturday AM).


Like all of the other resorts in Kenya, there is a very british colonial influence as evidenced by the tea in the above photo - note the birds helping themselves to the leftover milk :-)  

We decided to go hiking on the island to a few hot springs (red placemark) on the north end.  It was a really nice hike becase you're basically walking through a village and there are several of the local young men who "volunteer" to guide you to your destination.  Although, they work hard to be helpful without making you feel like you're in a tourist trap.  



I was having a really great time until about 50 feet from the hot springs when I stepped on a thorn.  I instantly became the spectacle with nearly 20 locals surrounding me trying to help get the remaining thorn out of my foot (Chris got some pictures, but I don't have them yet).  I was pretty gimpy, and was luckily able to secure a humilliating ride back to the camp on a boat.  The thorn will continue to be a topic as there is still a tiny piece (2mm - we did an ultrasound of course) that we're going to let "work itself out naturally" - yeah, I can't wait.




Despite the thorny start, we really had a nice time at Island camp.  We went on a boat tour of the lake and saw hippos, crocs (not the shoes), and many beautiful birds.  The highlight of the trip is when the boat guide buys some fish from the local fishermen to feed the fish eagles.  They stuff some balsa wood (naturally occurring in the area) into the fish, whistle for the eagle, and through the floaty fish about 10 meters from the boat.  The fish eagles spot the fish from hundreds of yards away and fly down close to the boat to grab the fish.  It's definitely exciting to see.  Again, Chris has some amazing pictures that I'll share when I get them.


There was a bar-be-que on Saturday night that was spectacular, and we stayed up drinking Tusker and playing cards in the camp's bar both Friday and Saturday night.  We found that Brett is exceedingly good at cards and exceedingly bad at hustling, which was good for the rest of us :-)


We decided to round out our trip with a visit to the hot springs of lake Bogoria as they were nearby.  Marissa didn't like the smell or the steam so we didn't stay long.  The flamingos were very pretty though, (more pics later).


Well, I'll leave you with a teaser for tomorrow's post - Today I traveled to Kogelo with friends, which is the village where Barak Obama's grandmother lives.

Thursday, January 15, 2009

What else?

 
Yeah, right - what else would you put in there?  The very fact that they have this on the bottle suggests it's been a problem in the past.  Or perhaps, it's just a reaction to The Gods Must be Crazy.

Back Pain for 6 Months

Sorry for the silence.  The power went out yesterday, and I'm a little GI sick today so I'm not moving as quickly as I could.  The following images are from the MRI scanner that I took a picture of a few posts back.  This patient has had back pain for 6 months, take a look at the images and see what you think.

 
  
 
Basically there is a giant mess of infection in this patient's spine from a long-term infection with tuberculosis.  Tuberculosis of the spine is also known as Pott's disease.  The sharp crook in her back is called a gibbus deformity.  This is something that you would NEVER see in the states, but is common in other parts of the world where Tb is endemic.  Other great cases from neuro conference include - a cervical spine astrocytoma, a rare sarcoma of the sphenoid wing, and a few meningiomas.

On this Tuesday we went to the orthopedic conference where the residents (a.k.a. registrars) discuss the patients that they have cared for over the weekend with the attending.  One patient had a horrible fracture of the right hip (acetabular fracture) from a tractor that fell on his pelvis. The registrar reported that the patient had been waiting for surgery for 3 weeks in the ward, and proceeded to describe a difficult course in the operating room because "the patient had purchased the wrong plate and screws" and it wasn't identified until the patient had already been sedated and an incision made.  They somehow made things work to repair his fracture, which looked decent on the post-op X-ray.  My jaw just about hit the floor!  I'm positive that the cause of the delay in treatment was because the patient was trying to raise the necessary funds for the hardware, which is just stunning.  The amount of pathology here is staggering, particularly in MTRH (Moi Teaching and Referral Hospital - the public hospital here).

Finally, the CT repair folks from Nairobi finally arrived (close to a week after they said they were coming) and are working on the CT machine.  Hopefully they will be able to return it to good working condition.  Unfortunately, the repair guy said that the CT scanner itself will not DICOM send.  The raw data needs to be processed on a workstation (read $$$) and then sent to an archive.  In non-geek this means that my dream for a basically free digital image archive for Kenya won't work with this CT scanner.  We'll have to wait until the next one comes along :-(

 
Another introduction - Laura and Tim.  Laura is a resident from Minnesota studying med-peds (I think?)  She's here on her third trip, and definitely is experienced in the ways of East Africa - she lived in Uganda for a year!  Tim has done half of IU Med School and is working on finishing his MPH at Yale.  He does research and works with the street kids who live here in Eldoret, I hear that they all love him and his big crazy hair.
Headed out to Lake Baringo Island Camp for the weekend, so more pictures next week, I promise!

Monday, January 12, 2009

I almost forgot.....

Dr. Wanene on Saturday took me to see one of the MRI scanners that is now here in Eldoret.  It's a Siemens 0.3T open-sided magnet.  One of the reasons for the low field strength is that it's a non-superconducting magnet.  The advantage of which is much lower maintenence including no need for liquid helium or liquid nitrogen, which I'm guessing are pretty hard to come by in Africa.

 
I feel both happy and sad about the arrival of MR in Eldoret.  I'm happy because it allows a completely new experience for the radiologists here, and I think it makes Eldoret more attractive to radiologists.  However, the poor people of the country who need our help the most do not have any access to these two machines.  There is no subsidy of indigent care at either of the two private hospitals.  I had never before thought that it would be technically possible to have MRI in Eldoret, and now that it's been done (and is being supported by manufacturers), I have hope that we could raise funds to purchase an MRI scanner for MTRH.  Especially in light of the increased interest in neurosurgery that I mentioned earlier.  If you're interested in contributing, send me an e-mail.

--Marc

Weekend + Friends Continued

This is my friend and colleague Kelvin (a.k.a. Kev-o).  He works with me in the radiology department doing 'computer stuff'.  He's a hard worker and a great guy to hang around with.

This weekend I got a bunch of work done which was good.  The server software has been nearly completely upgraded and is working pretty well so far, so I'm very happy.  This was a major jump, so there was some anxiety about making sure it went well.


Joe and Sarah Ellen have returned to Eldoret which has been really nice.  We went to the Oasis and had chicken, chips, and a chocolate milk shake with Peptang (as it should be).  


I have a bunch of work to do so I'm going to sign off.  Enjoy your gratuitous dog photos for the day.



Friday, January 9, 2009

Cast and Crew

I thought that I would take a few blog posts to introduce some of the people that I work with in Kenya.  Oh and no, Kenyans frequently don't smile for pictures, unless they have been hanging around a lot of Wazungu.
 
This is Pamela - she works for the MTRH IT Department (a.k.a. ICT).  She is one of the best people entering CXRs into the system.  Pamela has been working on RIS/PACS since I was last here in 2007.
 
This is Dr. Wanene - he is a radiologist and is excellent at ultrasound-guided procedures, as well as doppler examinations.

With regards to the computer project, I found yesterday a great little tool called jpg2dcm.  Given only a text file and a jpg image it creates a dicom object.  What this means is that we can now start a real image archive to house the CXR images.  We'll also then be able to use many of the available tools for viewing and manipulating dicom images.  I also think that the CT scanner is capable of dicom, and one of the ultrasound scanners may be as well.  We could be on our way to a real PACS system at MTRH, which I'm very, very excited about.


Last night the people who didn't go on safari this weekend put together a bonfire party with some of the Kenyans who hang around the house.  Tim and Benson got a goat, slaughtered it, cleaned it and roasted it over a fire at river house.  There was plenty of Tusker flowing, and the biggest pot of ugali that I have ever seen (the platter was the size of a trash-can lid, and the ugali was about 6 inches tall on it)!

Thursday, January 8, 2009

Dog Photos

Spent most of the morning hanging out with Dr. Abuya, which was nice.  He's very interested in improving the system for CXRs and supporting AMPATH.  I think that we're going to work with him on a small pamphlet describing basic CXR skills, which should be a good project.  I think that he's taking his academic career very seriously - I learned today that he is a Co-PI on a study measuring renal function in HIV patients that looks like it's very well designed and executed. 
Saw a few images from one of the Eldoret MRI scanners today and for heads they are really quite good.  One of the things that makes MR much more important now is that MTRH has a neurosurgeon.  He did a fellowship in neurosurgical oncology and spine and has been removing brain tumors, which is really amazing considering just two years ago if you were an idiot physician who travelled to Kenya with persistent headaches and a subdural hematoma you had to be airlifted to Nairobi just for a burr hole.  They also have a weekly multidisciplinary conference with radiology, neurosurgery, and pathology.  It didn't happen this week, but I'm looking forward to next Thursday.  Oh, and they are begging for someone to do cerebral angiograms for pre-procedure planning.
That's about it for today.  I have a bunch of work to do today, so I'm thinking that I will stay at IU house this weekend.  Here are a few dog pics to brighten your day :-)

 
 

Wednesday, January 7, 2009

Order in the Chaos

This image, I think provides a good description of what its like to work in Kenya.  Things are just a bit different.  At first glance the scaffold surrounding the building seems haphazard and insane.  It is especially unfathomable given western standards - this definitely isn't OSHA compliant!  I was marveling at the creation with one of my Kenyan friends who informed me that there is much more order here than I would have guessed: the trees are a very rare, valuable type that are very strong, light and thin.  The 'scaffold' is completely reusable - every joint will be untied and the sticks will be moved to the next construction site.  Despite looking disordered and useless, someone definitely put some thought and effort into the process.  The bottom line is the same: it provides a functional scaffold that allows completion of the task.  Working in Kenya frequently feels like a hacked together scaffold, but at the end of the day, it just makes an accomplishment that much more rewarding.
Yeah, there's a guy up there :-)
 
This is a shot of the road leading back to the IU house.  Everyday has been gorgeous with blue skies and wonderful fluffy white clouds.
 
Gratuitious puppy shot for the day (he was stretching).  Will snap some more dog photos in the AM before they cash out for the day.

Tuesday, January 6, 2009

No Trauma Today

Today I met with Dr. Kimutai, who is the new head of the radiology department.  We had a nice long chat about the future of MTRH Radiology.  It turns out that they face similar challenges to radiology department stateside - facing higher and higher volumes of studies with fewer resources and increasing levels of expected service.  Additionally, Joe Mamlin is pushing to perform chest X-rays at many, many more of the rural sites which will increase the volume substantially.  

In order to deal with the volume, we're exploring using a specially trained clinical officer (kind of like a PA) or a radiographer (X-ray tech) to read chest x-rays under the supervision of a radiologist.  With the database that we have in place we have the opportunity to do some really cool validation studies and to continuously moniter the quality of the non-physician readers, just to get our research feet wet.



In talking with Kimutai, I learned something else really interesting: in Kenya outside the public hospitals consultants expect radiologists to perform their own ultrasounds.  Moi Teaching and Referral Hospital (MTRH) is a public hospital, which is why they have been able to integrate the wildly progressive idea of a sonographer.  I hadn't realized that private hospitals didn't have sonographers until today.


Also big news: Eldoret now has two MRI machines (both in private hospitals). Both are low-field < 1 T.  Dr. Kimutai has started a neuroradiology conference with the neurosurgeons where they review CT and a few MR scans on Thursday mornings, so that should be interesting to attend!

Call me old-school, but Kenya just isn't the same now that they have actual Ketchup.



Dog pic for the day:





Well that's about it for now.


 

Monday, January 5, 2009

A Rough Way to Start

Well, it turns out that quarter 'til six and 6:45 aren't the same thing, although without much sleep yesterday I was thinking that they were. So, at 5:45 this AM I got a call from the center desk telling me that my driver was ready and waiting - crap. I had stuff strewn all over the room and packed like crazy, obviously no time to shower. Then, hurrying I fell down the stairs in the hotel carrying all of my gear.

I after I stood up I checked all of the important things: my laptop was intact, as was the Kindle *phew*. Oh and yeah, I'm alright too.

Definitely hope that doesn't foreshadow things to come for the rest of the trip.

Went in to the hospital and it was great to see all of the familiar faces. Evelyn, who I was great friends during my first trip has completed her advanced training in CT and has returned to MTRH.

The jetlag is hitting pretty hard right now so I'm going to sign off before I do more stupid things.

Sunday, January 4, 2009

Le Tired

Made it safely to Nairobi.  Great wireless access in the Hotel, and it's even free, which not many things are around here.
The flights went off without a hitch, luggage made it this far, and it appears that the laptop still works.  I don't sleep well on planes, so I think that I've slept about 4 hours at the most.  I was going to post a photobooth picture, but it's really not pretty.  Airplane food seemed more awful than usual.  Thank god for the fritatta that Lisa whipped up.

That's it for now, time for sleep.  Flight for Eldoret leaves at 0715 and I have to be there an hour early.