Friday, September 27, 2013

How Do You Eat An Elephant?

One of the things that's hard about traveling and working in Kenya is setting reasonable goals and expectations.  If you've been reading the blog you'll know that many things are very unpredictable.  Things that would only take a few days at home can take weeks or months.

I'm happy to report that while it's not ready for robust field work,  we are at a stage where we can test aspects of the truck with patients.  The picture above marks a milestone in our progress: the first X-ray of a patient obtained on the truck.

We still have quite a way to go, but we will continue to tackle it, one bite at a time.

With a Little Help From My Friends

When I asked the registrars what they would like to learn about they said: MRI physics.  In my head, I said "crap".  MRI physics is a subject that I've learned in the past several times over, and it's easy to forget and get confused.   I haven't looked over the material in quite some time, and I didn't have an easy outline or set of prepared slides - crap!

So, I asked for help from several of my colleagues: Drs. Buckwalter, Aisen, and Sandrasegaran all came to the rescue and gave me powerpoint lectures to use.  The registrars attended, and were attentive for 6 hours of MRI physics over a few days.  This post is a thank you to those who assisted not only me, but many young Kenyan radiologists.

Thursday, September 19, 2013

Humpty Dumpty

Today we had another bit of drama with the truck.  You can see a laptop affixed to a desk behind Clem, and then up above is our digital X-ray reader (worth about $25k).  During the three weeks that we have been working on finishing and testing, the truck has been in the exact same location.

In order to seal the roof, they wanted to move the truck into the sun.  Unfortunately, despite good instructions to the contrary, the truck was moved before the desk was permanently fixed to the truck.  The laptop and the digital X-ray reader took a tumble and fell to the ground.  The laptop had been fixed to the desk with Velcro, which did it's job and ripped the plastic covering off the bottom of the laptop.  The tray that holds the X-ray cassette busted into several pieces.

The good news is that we were very lucky.  The laptop booted right up without issue.  The CR reader was tested and appears to be functioning as expected.  I was also able to repair some of the damage to the tray with superglue without gluing my fingers together.  I think I did a little bit better than the King's men.

Tuesday, September 17, 2013

Fale with a capital F

For those of you reading along at home, you'll know that we've been pushing to get the X-ray truck operational before the end of my visit.  We were making pretty good progress, putting the finishing touches on the body - including placing the steel panels around the generator that were left out by the body builder.

Unfortunately, we've been stymied by the electrical system.  I've learned waaaay more about generators than I ever thought possible.  We went to great lengths to get a new part from Mombasa on Monday, and it was installed today.  However, despite assurances from the company and the best of our own ability, it did not solve our problem.  Sadly, this means that the truck will not be able to roll out fully functional by next week.  Fale.

New Treats

I got to try some new Kenyan food the other day.  It was actually pretty tasty!  I still stay away from ugali, but I'm a new fan of matoke - a kind of stewed plantain (pictured above) and githeri, which is a staple in western Kenya - kidney beans, carrots, potatoes, and corn together in a fairly dry stew.

This blog has a pretty cool rundown of Kenyan ethnic food, worth checking out:

2013 Kenyan Case of the Week

Post your answer in the comments.  Give the findings and your best shot at diagnosis.

The radiographers do all of the fluoroscopic exams here - these are the only pictures we had to make a diagnosis (the rest of the duodenum and proximal small bowel were normal).

Patient with long-standing history of dysphagia, vomiting, and early satiety.  Other history withheld.

Sunday, September 15, 2013

Weekend Update

Friday I spent more time working with the registrars - we went over some teaching cases together for about two hours, then I went to work on the X-ray truck.  We are completing several finishing touches, including finishing up the box that holds the cassettes.  We pulled the gas tank off of the generator and have called the vendor at least 3 times per day x 3 days.   Hopefully the generator won't prohibit us from moving forward for too long.  We may have to rig something up with a tube that feeds the petcock, will just have to see.

This weekend, I've been kind of a hermit programming.  I'm taking the opportunity to crank out some software changes that I don't usually get the time to concentrate on at home due to competing priorities.

Yesterday as a work break, I headed over to Patrick and Wendy's.  I thought that I was going to help brew some beer, but quickly realized that Patrick needed help building an extension to his fence so that Miwani (the cute little dog that we run with) won't be able to jump the fence to play with the kids next door.  Patrick has contributed so much to the X-ray truck that it was a lot of fun to be able to give a bit back.  I also got to work with Deb, another long-termer here in Kenya.  We had a great time.  Hopefully the extension will be able to hold the little dog back!

Sunday consisted of a short run, more programming, and another bike ride.  This time Patrick really kicked my butt.  We were riding through a field that had these big clumps of grass and tiny little cow/human paths that were like 5-6" deep ruts.  There wasn't a whole lot of pedal clearance and one time I clipped my pedal and "lightly" racked.  Overall it was a good challenge - it's so nice to be able to maintain some physical fitness while I'm here.

Thursday, September 12, 2013

Back to Basics

One of the things that I enjoy doing the most is teaching residents about doppler ultrasound with a hands-on lab, where I'm a patient.  It was developed over time with my good friend and colleague Angie Shah, the lead ultrasound tech where I work.  In fact, is much trickier (my glasses all funny so I can see the screen) to do the lab without her, as we have a great tag-team routine at home.

After the ultrasound course, we did a biopsy of a large abdominal mass and then we had tea and read some cases, nothing too exciting: normal barium meals (upper GIs) and chest x-rays.  After tea, we listened to one of the registrars give a lecture regarding gyn imaging before heading back to IU House for lunch.

The afternoon was filled with more work on the X-ray truck.  It's been a real team effort: myself, Patrick (the engineer who has designed and overseen the building of the truck), Phil (engineer spouse of an IU doc), and Peter (X-ray tech), as well as Patrick's staff at Wataalamu (engineering and maintenance).  Everyone has contributed something to this crazy project.  One of the things that you learn quickly working at Wataalamu is that nothing is wasted.  One of my co-workers was a little sad that I had temporarily misplaced a tiny screw for the plug to the X-ray generator, even though it was an extra.

Those small parts we take for granted at home just aren't available here.  In the picture above you can see the foam that lined the packaging for the X-ray machine.  Phil harvested the foam and repurposed it to support the X-ray cassettes in their holders.

He did an awesome job, and I can't wait to see it fully assembled.

Wednesday, September 11, 2013


I've been so busy with the truck that I haven't had much time to interact with the registrars.  I finally got some time to spend reading cases with them yesterday.  Again the case mix is heavy on neuro, and they were also reporting plain X-rays and fluoro studies, which have been fewer in the past.

The CT scanner is running a ton.  They are doing 25-30 scans/day which is a lot more than had previously been performed.  We were kept busy with many cases to report.

Today, I lectured on ultrasound physics and then we spent some time trying to do a hands-on practical, but alas we ran into equipment problems.  The Philips machine that we were using last year that was in great shape has deteriorated.  The workhorse curvilinear probe wires wore out and it's no longer usable.
The other ultrasound machine that they brought in seemed like it had the capability to work, but the pulse-wave would never update.  We ended up in the OB department borrowing one of their machines to talk about liver doppler.

It's heartbreaking to see equipment that can't easily be maintained.  Just another thing that we take for granted at home.

Monday, September 9, 2013

A Bit Tougher

I had a really beautiful start to my day.  I went running with Adrian, another one of the guys here at IU house.  Running with the sunrise and the mist and the cool temps was just amazing.  Better than the 90 degree days that Lisa keeps reminding me of.

I tried to go to the hospital today, but the pull of the truck was too hard to resist.  I hadn't yet seen the modifications that Patrick had made for the X-ray holder, and the generator guy was coming to help us troubleshoot our electrical issues.

After many, many tests we're not much closer to a solution to our electical issues and we suffered a pretty decent setback today: I broke the fuel petcock - a small device that prevents gas from reaching the engine.  It's important for engines that run on carbs as they can be easily flooded.  I wasn't even turning it hard, it just snapped off in my hand releasing a stream of gas onto the hot generator.   Luckily I was able to plug it quickly with my finger and we found some tubing that allowed us to drain the gas without fire, or getting it all over my clothes.

By the time that the generator fiasco was over, I had missed lunch at IU house so I dropped by Coolstream.  It's a restaurant that's operated AMPATH similarly to the Imani workshop.  I usually enjoy chewing through their food at least once while I'm here.  The entire plate of food above was only $1.72.

After retreating to the IU house, I was able to knock out some good fixes on the programming side of things, so I'm not completely bummed about the day's setbacks.  These things must be expected and seen as small bumps along the way, and I still have a decent amount of time to work.

Sunday, September 8, 2013

A New Adventure

Last year, when I got invited to dinner by a friend here in Eldoret, I noticed that he had a couple of mountain bikes, and I was really hoping to go for a ride during this trip.

Luckily we were able to find a time that worked for both of us.  Patrick brought his cute little pup who ran the whole way.  Only on the lead while riding or crossing busy streets.

We had a few times where the 'road' was intersesting, and with the rough nature of the roads in general, my butt and back are a bit sore.  Overall it was a really fantastic time, and an experience I won't soon forget.

Saturday, September 7, 2013

11 seconds

Today, we scheduled a morning trip out to Mosoriot, to test the network transfer of our x-ray images.  AMPATH has installed a wireless, wide-area-network that allows them to communicate with several of the outlying clinics in real-time.

We couldn't resist checking out the imaging facilities while we were there and found a real gem, a very old Siemens ultrasound machine that was still functional.  Having studied a bit of the history of ultrasound in order to understand physics it was really cool to get to see one of these in action.

You can see the old-school 5-inch monochrome CRT that displayed a flickering image.  It would have been super hard to see what you were doing for a biopsy!

After looking over the imaging facilities we went over to the data room, and clicked the laptop for our X-ray machine into the network.  A few clicks and we were connected and ready to test.  I got out my iphone stopwatch, and 11 seconds later we had uploaded our first X-ray remotely.  I was shocked, and really excited.  I expected a few glitches, but things went smoothly.  It was only a test, and of course things are different in production, but it's a great start.

Thursday, September 5, 2013

X-ray Truck Update

Here she is - our X-ray truck.

The generator is housed inside the truck for transportation and slides out super easily on a track into the running position.

Inside, there's space for the patient to stand in front of the cassette, and a small desk for the technologist to process the images.  Clem's sitting on a sweet stool that pulls out from the wall.

Here's Peter Otunga, our radiographer demonstrating the technique to take an X-ray.  There is shielding throughout the truck to protect the public.

Here's a picture of me in position, about to get an X-ray :-)  We were able to successfully take X-rays of a few of the people around.

The X-rays turned out pretty well - this was my first ever if you can even believe that!

We still have many, many bugs to work out and have lots of things to do to improve the process but it's exciting to see things starting to come together!

Wednesday, September 4, 2013


It may not look like much, but it really does symbolize a huge amount of work by many, many individuals.

This is a photograph of the first successful X-ray taken on our mobile X-ray truck with the systems in place, running on generator power.  It's a 'phantom' that I built out of a piece of wood, a wrench and a screw.  There's a little bit of cement on the right side (radiology left) of the wood which is making it stand out.

We have a long way to go, but I'm so excited to share this small bit of progress with you.  Stay tuned for more.

Tuesday, September 3, 2013

New Arrivals

I can't believe that this is the beginning of my 7th trip to Kenya. I've seen many changes over the years, but one particular change that stands out this year is the airport.  For those who missed it, the international arrivals terminal was engulfed by fire just a few weeks ago.

I had heard that we were being taken through the VIP terminal, where Kenya receives heads of state and other dignitaries.  I didn't quite know what to expect.

The first interesting site was deplaning on a giant staircase (watch out for hop-ons) from a 747!!  it was pretty amazing to look back at a 747 from the ground rather than the high-above-the-ground typical terminal configuration.  The next weirdness was that they boarded us on busses and took us to immigration.  Along the way, we saw numerous tents labeled international departures.  The departure gates are literally sitting on the tarmac under tents.  Turns out that immigration was also in a tent (which was donated by US-AID).  The good news is that it was adequately staffed: two people to take care of a plane with 400 travelers.  I was lucky to be in the middle of the line, and it only took two hours!  

The domestic departures have moved to a giant cargo warehouse, as the international departures have taken over their prior locale.

The capacity to adapt is what's really been astonishing about the whole thing.  With a few small cosmetic differences, the experience was roughly similar to years prior.  I arrived in Eldoret without major issue or complication.

Sunday, August 25, 2013

Litchen (Living room + Kitchen) Remodel

We decided to redo the kitchen and the living room at the same time. One thing we love to do is entertain, so we reconfigured the living room so that it could intermittently play dining room.  Our new kitchen table plays double duty stretching from a 5' x 5' square to a 10 person monster in the living room.  It lives most of the time in the kitchen, but can be moved to the living room when needed.

In order to make the new table play nicely in the living room we needed to change the room configuration. We ditched the coffee table, in favor of a long-skinny coffee table that doubles as a bench seat. We updated one of the couches and replaced the other with two chairs that can easily be moved to the side when needed to accommodate the big table.

We also decided to redo the kitchen in a mostly budget fashion. We repainted the cabinets, installed some sleek LED undercabinet lights and had a tile backsplash installed. We're thrilled with the results and *almost* came in under budget for the whole project :-)

Sunday, August 4, 2013

Next - Vegan

After our trip to Chicago to enjoy The Hunt at Next, we were thrilled to score tickets to return for Vegan.  Phil Vettel from the Chicago tribune in his review of the Vegan menu called it "culinary theater", I couldn't agree more.

Our neighbor Ryan was able to join us again, and we were thrilled for Jon to join us.

 Anticipating the awesomeness.

The first few courses were a bit of a whirlwind.  Of course, there was a welcome letter (in the tree above and featured below).  The tree is also decorated with sourdough crackers that were dusted with green tea matcha powder.

The first course of burnt avocado, kale, and sesame and beautiful flowers (below) was enjoyed on the crackers.  The spread was quite tasty, but the crackers were brittle, chewy, and disappointing.  Lisa and I were a little nervous about how the rest of dinner would go.  It was especially touch-and-go as we were with two of the most staunch omnivores that we know :-).

The next two dishes came out in rapid succession, far before anyone could consider finishing the crackers.  Potato skins filled with potato sorbet and topped with scallions were a fun play on texture.

Next came the log that was dotted with red and green treats.  The green hemispheres were a mix of sushi nori that was cooked into a dumpling with some kind of cracker.  It was a yummy veggie bite of the sea.

The red spiky things are rambutans.  They are a tropical fruit (I first had them in Vietnam), although this was a rambutan/earl grey custard that was served in a rambutan half-shell (detail below).  It was a clean palate cleanser with hints of bergamot.

Just a tiny bite of tempeh.  Tempeh is definitely not one of my favorite vegetarian/vegan foods.  Most people serve it as a terrible meat replacement.   It's clear that the folks at Next (Grant Achatz and Dave Beran) know how to cook.  They took something that usually sucks and transformed it into a delectable bite that left you wanting more.

Below is the last of the small plates - phew!  Grilled artichoke hearts which were surrounded by a light citrus artichoke puree before being placed back in burnt shells.  This was probably the #2 favorite of the small bites behind the tempeh.

Next came one of the best dishes of the night.  Definitely one of the most unique presentations I've seen.  They brought a glass decanter and funnel with a strainer to the table first.

Next, they brought out a huge log with a charred hole in the top.  

Our server started to describe the dish as a celebration of the apple: green apple shaved ice, lactose fermented apple, and from the log: apple cider vinegar from an 8 year old mother, which was served as a beverage in champange flutes.  The apples were paired with rose petals, and rose candy.

In addition to the tree on the table, there was a small 'lily pond' that had several small greens floating in it.

For the next course, the greens were fished out of the pond and assembled at the table with soft, tender lotus roots.  The dish was very fragrant and light.

 Lisa's famous for smelling food, but we were all nosing hard on this.

After this course, the table was covered simply and elegantly with a pristine white tablecloth.  The next dish included the drink pairing incorporated right into the plate.  The cocktail was chilled with liquid nitrogen in the glass sphere below the plate.  When the plates arrived from the kitchen, the hole was covered by a second glass sphere.  As the liquid nitrogen evaporated, the ball bounced on the plate creating a symphony of clinking.

The dish was a riff on strawberry shortcake including fennel and fermented rice yogurt.

Ryan demonstrates the cocktail.

Next up was a true piece of culinary wizardry: salsifies with oyster mushroom and dandelion.   The chefs transformed a root vegetable and greens into a vegan reproduction of mignonette-dressed oyster, and a yummy salad of dandelion greens.  Usually we're not up for 'meat replacement' dishes, but every rule has its exception.

Paying homage to european cheese carts, a cart full of beautiful mushrooms passed through the dining area.  It wasn't clear initially, but this was just a visual showcase of the high-quality ingredients being employed.

Next up was a beer-battered, perfectly fried leaf of swiss chard (left), which is hiding a cluster of tasty beet goodness.

The chard leaf was paired with a wonderfully salty chard preparation that included douchi - a fermented and salted soybean from Japan.

The next dish featured kombu and house-made yuba, which is part of the tofu-making process.  I was lucky to have recently honed chopstick skills in Vietnam, otherwise this one would have been a great challenge.  The presentation was really pretty coupling the wavy bowl with the wavy skin of the yuba.

Next, they placed this test-tube log combination on the table.  They wouldn't say much about what it was for, and left it as a conversation piece.

Next came a barley risotto that was dressed with beautiful flowers and other yummy treats.  Just a few bites, of this rich dish and we were all starting to get full.

Next was a play on Thai/Lao larb.  A dish that typically combines pork, ground toasted rice, sticky rice as well as fresh vegetables.  This version featured a nest of toasted quinoa, and was visually splendid.

Lisa's horror at finding out we were about 60% through - poor thing was stuffed already!

Probably the number-one dish of the evening - the roasted cauliflower with harissa and house-made fresh naan.  The mystery of the test tube was finally solved - after removing the sprouted bean, we used a chopstick to push the spices on top of the cauliflower waiting below.  This one was so yummy so despite starting to get full, I was more than happy to polish off Lisa's extra.

The first of the dessert courses - a lovely chocolate crumble that was accented with a clear concoction of olive oil and Szechwan peppercorn.  Before sampling they give you a spoon that looks empty to lick.   Turns out that it's coated with more of the clear sauce.  Mouths tingling with peppercorn, we dive into the chocolate goodness.

Lisa showing off the last drink pariing of the evening - a cocktail featuring lambrusco, metzcal, vermouth.

The second dessert course: hibiscus and a pistachio mousse.

Now we're all crying uncle - stuffed to the brim, when they bring out two towers of steamed crepes: creme brulee, passion fruit and chocolate.  Wow.

We had an absolutely fabulous meal.  We had to keep reminding ourselves that it was actually vegan, it was just so easy to get caught up in the excitement of what's coming out Next.