1/11/10 Thoughts from Chris

Wow, where to I start - what a day - it’s about 20:00 and I’m just now getting back to the farm. I’m not sure how to start. So it goes something like this: This morning, after about a 1 mile muddy walk in the rain down to the dispensary, Victor, one of the persons living at the Kibaritas, came running to the clinic saying that Margaret, one of the ladies who works on the farm, was found passed out in the field and that she wasn’t making sense, or that’s at least what I could make out from the broken translation of a frantic Victor. My immediate thought was, “Oh, great. Someone who has been working in the field and didn’t drink enough water because most Kenyans don’t drink enough water. She must be dehydrated. No big deal.” So I walked another mile back to the farm to check it out. I did not run - I really thought it was no big deal. Was I in for a rude awakening! By the time I got there, she was laying in the grass face down in her own vomit. I immediately took her vitals. She was found to have a Blood Pressure of 260/140 - yes, that is correct - not a typo. It was repeated 3 times on each arm. Her heart rate was in the 50’s. So, as an aside, it had been raining and if you haven’t been able to catch up with Sara’s blog, the road from the town to the farm is passable by a donkey or dirt bike. There’s no such thing as 911 or an ambulance out here. Long story short, we were, by the grace of God and a very generous man with a 4 wheel drive truck, able to get her to the front gate at Mukeu, after which I carried the lady to the dispensary as by this time she was becoming even more unresponsive, responding only to painful stimuli. We were able to administer 20 mg Hydrolyzing (a blood pressure medication via IV to help lower her BP) and it dropped to 200’s/100’s. Our immediate concern was….stroke. In the US, we can call 911, have a rapid response team arrive and wisk her off to the nearest latest and greatest stroke center. But this, as you know, is NOT the US. We were finally able to call a family friend who has a taxi as most people do not have vehicles here, which would have to suffice as an ambulance, myself and Monica, a family friend, would travel with Miss Margaret through muddy roads to the nearest hospital, Kijabi, a local mission hospital. The drive was somewhat treacherous, even nauseating. It was all I could do not to choke from the stench of her own vomit all over her and now me. After getting to Kijabi, I was very blessed to have run across another American doctor working there. I told him the brief story and we were able to take her back immediately to “Casualty,” which appears to be their equivalent to the ER. After speaking to one of the residents taking care of her and examining her with him, it appeared as if she indeed had suffered an MCA stroke and he requested basic labs/etc. “Sure!” I thought. “Sounds good to me!” A few labs and a STAT CT of the head to look for evidence of a bleed/stroke, right? Well, not exactly. After speaking with the resident, the nurse handed me a bill and instructed me to go to the cashier window. And so commensed my education of the Kenyan health system. Before obtaining these labs/etc, you must pay upfront. If you want a CBC, that’s $5 or 35 KSH. If you want a chest X-Ray, that’s about $20. All in all, just for the basic work-up (not truly an admission) was 4500 shillings in cash. Then after you pay, they give you receipts and you, not the nursing staff/MA’s, take the patient to the X-ray lab. You must help hold the patient’s arms and lift them to get the x-rays. Let’s just say this is a different experience than in the US. After all of the tests were obtained and we had been waiting for quite some time, the brewing, impatient Muzungo (that’s me - Muzungo is the Kenyan word equvalent to Greengo/white person), found out that there is no CT Scan available; in fact the nearest one is clear in Nairobi. Even if it was possible to do this, neither Monica, the family friend, nor myself, the “rich “Muzungo” could afford the cost of transportation, let alone the expense of a CT Scan. And, by theis point, it was too late for any immediate intervention. The damage had been done. I was unsettled to say the least. Finally, after composing myself from all of this frustration, the determined, by this time angry Muzungo (that’s me, again) forced one of the “consultants” as they call them (we call them admitting docs) to review her story. He was a fellow American Family Practice doctor. He agreed that she would be admitted to the hospital. Finally, after nearly an 8-10 hour ordeal, I could rest assured that we could get her admitted. But this thought came too soon. To keep this story from getting any longer, I will just say that after 2 hours of negotiation with the disposition counselor who informed us that we would have to pay a 10,000 shilling deposit before the patient could even be admitted, I finally convinced them to waive the fee, and she was admitted. What I thought was going to be a bogus call for a syncope episod, turned out to be a devastating stroke and a raw education of a somewhat different medical system than I am used to. I wish my story ended here. I wish I could say that this lady, Margaret, was not a single mother of 5 children, the oldest of whom is 17 years old. I wish I could say that she recovered completely to go home to her children. I wish I didn’t have to tell a 17 year old boy that he is suddenly the caretaker of his other 4 brothers. While I may never understand, I do pray again for a miracle and a fresh touch of God’s grace. What a day.