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!