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.

Battle Hymn of the Baboon Mother

"In Kenya anything is possible". That phrase would be a lot more reassuring if it wasn't referring to the feasibility of fitting five people on to one motor bike. However, making things work with limited resources is definitely a necessity here. My second week on labour (British spelling) and delivery went well. I think I'd now feel reasonably comfortable if I had to do a normal delivery somewhere random without supervision. Let's hope that never happens...but it's good to be prepared.

There's certainly plenty of babies to keep things busy. Large families are still the norm here and one nursing student even asked me if I felt lonely just having one sister. I love my sister dearly, but one was plenty if you ask me. Over a dinner of Nyama Choma (roasted meat) with some Kenyans, I learned that they think Americans worry way too much about their kids instead of just letting them learn and grow naturally. Apparently another common saying is that your biggest blessing may still be inside you, meaning that you want to have as many kids as possible because who knows which will turn out best!

Children are often raised in a village surrounded by many relatives who can take care of the kid if the parents aren't around because they live about 10 feet away. Just the environment in which kids grow up here is so different from that in suburban America where you live in isolated houses usually far from other relatives. These differences are adorably illustrated in the movie Babies, which follows four babies (from San Francisco, Japan, Mongolia, and Namibia) through their first year of life. Honestly, I think by the end of the movie the African baby is the most self sufficient...she can even balance a bowl on her head while walking. Although my feelings about larger families have started to shift recently (I always thought 2 kids was the perfect number but now 3 seems like a possibility) I can still safely say that 11 is too many and some good family planning would be the real blessing here.

I wonder how Kenyans would feel about China's one child policy. I have a feeling that most would find "Battle Hymn of the Tiger Mother" completely ridiculous. Of course, there's a big difference between raising a child who can function in a rural village and one who will succeed in New York City. Torturing your children probably shouldn't be a valued parenting technique in any setting, but demanding hard work and discipline seems reasonable. I really hope I don't become a completely overbearing mother.

We saw lots of baby animals at Lake Nakuru this weekend. Baby rhinos, baby zebras, and baby baboons. Amazing. We even saw a leopard walking through the forest this morning and two female lions relaxing after killing a poor water buffalo (with hungry hyenas waiting in the background). It's the circle of life (cue Elton John).

Out of Eldoret

Jambo! I've now been in Kenya a little over a week and I'm starting to get into the swing of things. It's great to be a part of the IU-Kenya Partnership...there are so many amazing public health programs going on around here and I plan on learning much more about them during my stay. Right now I'm living in the Kenyan medical student dorms which are almost on par with Bard Hall accommodations at Columbia in November (though I do have to walk up to the third floor for bathrooms and there are no showers). Fortunately the IU House is nearby and offers warm water, laundry, and the internet!

My first day on the Labor and Delivery ward at Riley Mother and Baby Hospital was quite overwhelming (and not helped by the fact that I got up at 2:30 a.m. to watch the Packers win the Super Bowl). I got to participate in a C-Section within my first hour there before I even really knew where anything was and what was going on around me. Fortunately babies are born the same way where ever you are in the world, though the amount of support (and pain management) given to the mother varies dramatically (or is essentially non-existent here). The main difference with C-Sections here is that mothers are put under general anesthesia instead of receiving spinal anesthesia so you have to move even quicker to get the baby out before it goes to sleep too. I've never been that much of a surgery person, but C-Sections are fun! Since I'm working at Moi Teaching and Referral Hospital the C-Section rate is much higher than I expected...out of the ~700 deliveries per month almost a quarter of them are C-Sections. All of the mothers from small villages who are having problems or expected problems with labor are referred here so there are always interesting cases.

Fortunately there are a lot of normal, healthy births too. So far I've gotten to do 3 deliveries and I hope to do many more in the upcoming weeks. I've also seen a vaginal delivery of two breech twins (they would have had a C-Section in the U.S. and a C-Section here if there had been time) who were born in the chaos of the examination room soon after the mother came in. It's a great opportunity to learn about the normal progression of labor, but it's not necessarily the conditions under which I would want to give birth. There are 3-6 women to a room on rickety beds (though it should be noted that at least they get their own beds unlike the patients on the medicine wards) and supplies are never available when you need them. Yet, an amazing amount of the time things turn out well with few complications (though there is more post-partum hemorrhage). Now that I sort of have my bearings I really hope to learn a lot in the next couple of weeks on L&D.

Last weekend we went on a fantastic trip to Lake Naivasha and Hell's Gate. After a bumpy ride from Eldoret to Naivasha we took a late afternoon boat ride to Crescent Island where they filmed much of "Out of Africa". We saw many hippos lazing about in the water, elegant giraffes, and lots of zebras (the horses of Africa). The next day we went biking at Hell's Gate and saw many more animals (including warthogs and baboons) and hiked through the Njorowa Gorge near the Central Tower which is a volcanic plug much like Devil's Tower in Wyoming. Then we stopped at the equator on the way home. Hopefully I can post some pictures soon. This weekend I'm taking the opportunity to relax and explore Eldoret a little, but hopefully many more exciting trips are on the way!

Radiology

You'd think that with an art history minor I would be more interested in a field as visual as radiology...but instead just thinking about a future as a radiologist helps me better understand the phrase "you could not pay me enough to do that." And what exactly is the payment in question?!? Apparently the median income of a radiologist in the United States is $417,000...and that's for working reasonable hours.

I actually enjoyed most of my radiology rotation, lots of lectures from good teachers that helped tie together a lot of knowledge. Radiologists are excellent at coming up with a differential diagnosis and knowing how to rule out worse case scenarios. But you basically never interact with patients, sit in a dark room all day, and have to actually understand physics which was never really my thing. Interventional Radiology is somewhat of an exception in that it's an awesome, awesome, incredibly amazing field and I think it could be really cool to stick catheters in people and fix all sorts of problems...if only you didn't have to be a radiologist first. Radiology is hugely important in so much of modern medicine and the field is improving all the time. The new technology is staggering...fMRI, PET Scans, it's only going to get better. I now feel more confident reading chest X-rays, and even CT scans, myself...I'm just glad that in the future I can work with skilled radiologists and focus on other areas of medicine.

And now for something completely different. After a whole month spent staring at images from million dollar machines, it's off to Kenya where you're probably lucky to get a chest X-ray. It's going to be a new, crazy adventure and I can't wait!