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: http://migrationology.com/2011/06/kenyan-food-overview-20-of-kenyas-best-dishes/


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

Registrars


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

Progress



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.