Graduation!!!

That's Dr. Lianna Jean Heidt! Goodbye Medical School!

History is a Spiral

Yesterday was the last class of my medical school career! Do I really know everything I'm going to know when I start internship? Scary.

My History of Public Health course has been very interesting. If I didn't have this final paper on "The Rise of Cesarean Sections" hanging over my head I could probably spare the time to be more reflective about it. This pretty much sums up my paper.

Guns, Zebras, Germs, and Steel

When you hear hoof beats think horses, not zebras. That is often repeated advise when trying to arrive at a medical diagnosis...common diseases are common, and while your patient may have some incredibly rare infectious disease, it is way more likely they have the flu. Throughout residency interviews the horse vs. zebra issue was a frequently asked question from students because ideally you want to train in a hospital where you see both bread and butter pediatrics so you know how to handle the most common things but in order to expand your knowledge base and keep things interesting it's always good to see a fair number of unusual diagnoses too. I think CHOP has a great balance.

Of course, in Africa there are a lot more zebras. Malaria, meningitis, TB, leprosy...it's all here. In combination with seeing more serious diseases because people wait longer before seeking medical attention, the variety of diseases encountered makes training in a developing country very rewarding when it's not totally chaotic. I really enjoyed my time in Eldoret and will carry this experience with me in my training to come.

Zebras are definitely exciting, but unfortunately for the course of African history, apparently they are hard to domesticate (they bite and don't let go). Fortunately there are some domesticatable animals here, including the Arabian Camel. I'm on the Kenyan coast for my last few days of vacation and visited the amazing town of Lamu. There's a large Swahili presence there and the town is like nothing else. On a secluded beach outside of the village I stumbled upon a camel and got to go for a ride. Incredible! Now I'm relaxing in the tropical paradise of Watamu before making my way further south to Mombasa, taking the train back to Nairobi, and heading home. I can't believe this adventure is almost at an end but I've certainly enjoyed the safari.

The Second Sex

A peacock at Poa Place. Why don't all men work so hard to impress? Apparently the bride price for a female doctor in Kenya is 20 cows. At least now I know what I'm worth...

Towards the end of a talk about family planning I was giving to the parents of pediatric inpatients a woman raised her hand and said, "My husband got mad at me when he found out I was using Depo-Provera without telling him. He does not want me to use any type of family planning. What should I do?" Several other women in the audience related similar stories and turned to me for advice. While I was prepared to talk about the benefits and drawbacks of different forms of birth control and which types are best to use in certain situations, I was not sure how far I wanted to venture into thorny issues of gender politics (I think I had already alienated most of the men in the audience just by mentioning the possibility of vasectomy). However, the issue of who gets to make these decisions is truly at the heart of the battle for better family planning. Many of the women were already very well informed about the different contraception options and knew how to acquire them. The more pressing problem was how to get everyone to see the worth of family planning in a country that so highly values fecundity.

I weakly answered that ideally partners decide together what type of family planning best meets their needs but ultimately a woman should decide what happens to her own body. What I wanted to add but didn’t is that you should not have to put up with a mzee who dictates everything you do. Of course, many women are without other viable options. Kenyan women are hardly alone in their need to operate in a male dominated world, but many of them have limited access to the education and the resources that could make a difference. Trying to change cultural beliefs in a one hour talk in a country where a man can still have two wives may be out of the question, but I hope that in some way I planted a seed that an alternative is possible. Providing birth control, colposcopies, and anti-retroviral medications is essential for women’s health, but it is also important as a demonstration of solidarity and a sign that they do matter and their well-being is a priority.

I have seen many strong women during my time in Kenya, the doctors and nurses who stand up for their patients’ best interests and gradually push their male counterparts towards change. However, I will take back with me even more stories of women who have been left in unconscionable positions. The woman with nine children who just survived severe post-partum hemorrhage due to uterine atony but is afraid to even consider family planning. The HIV negative woman who has three children but just got re-married to an HIV positive man and is desperate to give him children for fear he will leave her. The woman with a tumor destroying her brainstem whose husband got her pregnant within two weeks of her discharge from the hospital and then abandoned her three months ago when she slipped into a coma. All of these stories could happen in the United States, but here they sometimes seem more the rule than the exception. If only changing the systematic ways in which women are undermined were as simple as treating gonorrhea. Hopefully by giving women more control over their bodies through family planning and offering them a reprieve from the constant demands of child bearing, women can gain the footing they need to start working towards improving their position in society in other meaningful ways.

Dr. Washington thinks we need a revolution...and I don't disagree. But how to start?

The Constant Gardner

Riley Mother Baby Hospital!

I matched at CHOP!!!!! Pediatrics here I come. I'm so totally thrilled with the program. And nervous about residency...but I'm ready for three intense years and I feel like my experience here has also somewhat prepared me for situations where I feel like I'm in over my head. Still, I am grateful that I will be training in hospitals where I will have lots of supervision for the next several years. When I think of my Kenyan colleagues who may soon find themselves practicing in smaller hospitals where they may have to do emergency C-sections and manage whatever comes their way with very little back-up, my future training opportunities seem almost sheltered. While I look forward to taking on more responsibility as a resident, I am glad I will not be practicing on my own in Kapenguria anytime soon.

Last Wednesday I went with Dr. Mamlin (the Godfather of our program) to a peripheral clinic site in the village of Mosoriot. The extreme poverty and decimation that HIV has caused were unbelievable, but at the same time the hope provided by Dr. Mamlin and AMPATH and the obvious progress that has been made in the fight against AIDS is incredible. Several of the patients were men weighing less than 40 kg...I weigh about 52 kg so you know something is horribly wrong. I met a former Olympic runner, now ravaged by HIV, and a woman who had all been given up for dead with HIV, thyroid storm, and two broken legs. Dr. Mamlin was going to make her walk again.

I asked him if AMPATH has grown naturally as a program, creating new programs to meet the needs that arise. His response has really stayed with me...the natural state of a program like this is entropy. Nothing comes easily, everything is a struggle. So you just have to keep fighting. Endelea!

Fortune Is A River

This past week I attended dysplasia clinic which mainly screens women for cervical cancer. Unfortunately in a country where routine Pap smears are essentially nonexistent and AIDs rates are high, cervical cancer is a major problem (but of course it's only one among many major problems). Gardasil, the vaccine against the Human Papilloma Virus which causes most cervical cancer, just came out in the U.S. a few years ago and has gradually gained more wide spread use there (and hopefully soon it will have even more use after this study showing that it protects men too...and dammit they are definitely also a factor in spreading it to women). However, Gardasil's effect on mortality related to cervical cancer in a developed country that already has good screening is small compared to the effect it could have in a developing country. While vaccination is no replacement for having good access to health care it is certainly a step that could save many lives. Unfortunately it all becomes a matter of cost...and a few donated vaccines just aren't going to cover it. Fortunately there are organizations such as Universities Allied for Essential Medicines that might actually make a difference.

For at least one of the women I saw last week the vaccine wasn't available soon enough and we had to break the news that she had invasive cervical cancer. Since I'm interested in a career as a pediatric oncologist I'm always curious to observe how people break bad news. The realistic optimist in me believes that it's essential to strike the right balance between acknowledging the severity of the situation but also focusing on the positive aspects and what can be done to help. Especially in a country where women have so little access to health care it truly is a blessing that our patient received screening so that her cancer could be caught at an early stage when a cure is possible instead of at a much later stage when she really would be beyond hope.


This weekend a bunch of use went white water rafting down the Nile in Uganda which was AMAZING!!! Okay, I was terrified before going, but after going through a bunch of grade 5 rapids and not dying, I actually started to enjoy the trip. And swimming in the water as the current carries you downstream was idyllic (as long as I didn't pick up schistosomiasis...Africa can kill you in so many different ways). I was lucky to have a great guide and be in a boat of like minded people who didn't necessarily want to steer directly into the biggest rapids. Those are always key things to have with you as you get swept down the river of life. You can also attempt to divert the Arno--give some chemotherapy, perform a total hysterectomy, build a dam, etc--and hope you survive with all your limbs intact.

Mountains Beyond Mountains

This was my last week on Labour and Delivery and I'll really miss the excitement of deliveries (karibu mtoto! welcome baby!) and being there to support the mothers through the whole crazy process. So much fun! And so unpredictable...just when everything seems to be going smoothly you get arrest of labour, or a prolapsed cord, or an arm sticking out of the cervix. Anything is possible!

One case that really stuck with me this past week was of a woman my age who was hospitalized with pre-eclampsia and HELLP Syndrome (Hemolysis, Elevated Liver enzymes and Low Platelets). She had lost three previous pregnancies around 6-7 months gestation due to similar health problems. Even though she was only at 28 weeks we decided it was in her best interest and the best interest of the baby to do a C-Section. An ultrasound showed that the baby was estimated at just over 1 kg which was somewhat hopeful since the mortality rate here for babies below 1 kg is 100%. The surgery was also high risk because since the mother had low platelets she had a high risk of hemorrhage. Everything appeared to go well surgery wise and the baby was born weighing 1.08 kg. What a little thing...we had to bag mask ventilate it...then it would cry, then it would stop breathing all together. I've never seen such a little newborn baby except already all wrapped up in an incubator. It most reminded of the newborn mice I used to dissect that had such thin skin you could see all of their internal organs. So fragile and born way too soon in a harsh environment without the resources to keep it a live. I had so much hope...but the baby died at 3 a.m. the next day.

Then we came in several days later to learn that the mother had suffered a hemorrhagic stroke overnight due to her hypertension and low platelets. While the neurologic deficits are still not completely known, any injury to the brain that can be easily identified by anyone looking at the little CT scan results on film has got to be pretty severe. What was already a sad case of a woman whose body just wouldn’t let her have a healthy pregnancy, is now endangering her life and will undoubtedly have lasting consequences. Tragic. Would better monitoring have helped? Certainly the baby would have had a much better chance if it was born at the other Riley. Now I just hope the mother can pull through.

This past weekend I climbed Mt. Elgon, the second highest mountain in Kenya, with a fellowship worthy of The Lord of the Rings…three Americans, three Swedes, two Canadians, and an Englishman. Our guides with AK-47s lead us up the mountain across moorland with funny looking giant lobelia and then scrambling up the side of a cliff to the peak of Koitoboss at 4187m. The view from the top was amazing with rolling mountains and farmland in the distance. We could also see Uganda (and apparently the Ugandan poachers still do some elephant hunting in the area which is why the guards were armed…yikes). I definitely reached my physical limit, but it was worth it. The following morning we explored the elephant dung and bat filled Kitum Cave and I stood beneath the falls at the gorgeous Makingeny Cave. Apparently these caves are ground zero for the Ebola outbreak in "The Hot Zone". Let’s hope the only thing I took away from Mt. Elgon were the memories (and sore muscles)…there’s enough of a strain on the medical resources here even without a major epidemic.