Urology Conference

The surgery workshop was organized in conjunction with the Kenyan Urology Society annual scientific conference, which capped the week’s activities. I had submitted a research abstract to Dr. Kanyi about a month ago, and he invited me to present it at the meeting! We arrived at the Panafric Hotel, one of the nicest hotels in Nairobi, at about 9:15 for the advertised 9:30 start. I know, not smart with Kenyan time, right? We figured that this would start on time. The conference hall where we were supposed to be holding our meeting was full of pulmonologists discussing asthma. Apparently the hotel had forgotten about our meeting, despite a large exhibit hall filled with pharma reps hawking medicines for BPH (benign prostatic hyperplasia). Oh well. We just relaxed on a large outdoor porch and enjoyed some chai, cookies, and the morning sun.



I spotted the business center, and quickly popped by flashdrive into the computer, as I wanted to a few words on my PowerPoint presentation. All of the files on my flashdrive looked a little weird, and I couldn’t open my presentation! Fortunately, I sent myself the presentation on email, so I just re-downloaded it and saved it on my flashdrive. That worked fine, but I later found out that the business center computer basically erased my flashdrive! All 6 gigabytes! Fortunately I had backed it up a few weeks ago so I didn’t lose too much, but it’s pretty annoying that the business center doesn’t have better virus control. Maybe global health should expand to include computer health care (terrible joke).

At about 11:00 am, we were finally invited to go into the conference hall to get started. Kenya has about 25 urologists, nearly all of whom were in attendance, along with some general surgeons, residents, and nurses. I was the only med student at the conference, we think because the fee for the conference was pretty high (2,000 KSH, or $25). The conference consisted primarily of 15 minute presentations on various research projects that people have been working on. I presented on the rate of urinary tract infection among pregnant women at the hospital where I’m working. It’s just preliminary data right now, but was happy to be able to present and get some ideas from urologists for the follow-up study that we’re about to start.

Amazingly, we made up time and actually finished up at the prescribed time! We then headed over to the Nairobi Club for dinner. This is an old social club built by the Brits over 100 years ago. Lawn bowling? Cricket? A spot of tea? All could be had here. We had the main dining hall for our function. As we were enjoying a beer before dinner, word trickled through that Raila Odinga, the Prime Minister of Kenya, was apparently in the house. I never saw him, but I’ll believe the rumor.



Dinner was good, and afterwards I went back the guesthouse to get some sleep before my early flight back to Mombasa on Saturday morning. All in all, the week was even better than I had expected. Aside from the ambiguity of what we were actually going to do upon arrival, it really couldn’t have gone better. I met a ton of urologists who invited me to visit them at their various hospitals around the country. After seeing the generalist model of care in Msambweni, it was interesting to be part of the more specialized delivery at the tertiary care hospitals in Kenya. Hopefully I’ll have more to report soon!

Currently we have a full house here. Four colleagues are here from the US, so we’re really busy trying to plan for our next (and last) few months here.

Kidney Transplant

On the final day of the surgery workshop, I was invited to help some of the adult urologists with a kidney transplant! KNH is one of only three or so centers in Africa with transplant capabilities. Their first transplant in Kenya was performed in 1978; the recipient was a young gentlemen whose kidney was removed because it was identified as an abdominal mass on an imaging study (he had “horseshoe kidney”, which results when the embryonic kidney fails to split in development). After that first surgery, the poor guy obviously had “renal failure”, but fortunately his loving sister was willing to spare a kidney for him, and they both walked out of the hospital two weeks later (with fantastic spread collar suits and afros, as this was 1978).

I scrubbed for the donor nephrectomy (where they take out the good kidney that is to be transplanted). It didn't do much but retract, but it was really cool to see the process. The kidney is very deep in the back/side, so it takes quite a bit of effort to get good visuals on the slippery guy. While we were harvesting the kidney, a vascular surgeon was preparing the site on the recipient where the kidney was to be attached (it's in the pelvis).

The surgeons freed all around the kidney, ligated any extraneous arteries and veins (such as those going to the adrenal glands which sit on top of the kidneys like little hats), and finally, clamped and cut the renal artery and vein, which supply the bulk of blood to the kidney. The main determinant of graft survival is “ischemia time”, or the amount of time that the kidney isn’t attached to the blood supply. It was definitely short in this case! We got the kidney out, someone ran it over, and by the time we were done closing the incision on the donor, the kidney was in the recipient and already making urine! Pretty amazing.

Rather than an intraoperative picture, which may offend some stomachs, here's a picture of a cute kid:



And part of the team at the end of the day:

Surgery Workshop

After visiting the wards, Dr. Kanyi guided us to the OR locker rooms. We changed into scrubs, and I was treated to size 10 surgical boots, which were fantastic on my size 14 feet. Then, the cases started. The week was dedicated to hypospadias repair. I'm going to briefly explain what this condition is, but if you're squeamish, you might want to skip to the beginning of the next paragraph. Hypospadias is basically when the urethra does not extend to the tip of the penis, but rather opens up somewhere on the underside. It varies case to case; in some boys, the opening is nearly at the proper position and it causes little problem, but in others, the opening can be in the area of the scrotum or even further back, leading to obvious problems with urination and having babies “the fun way”, as one doctor put it. The aim of hypospadias repair is to essentially make a new urethra that opens in the proper place. The difficulty varies depending upon the location.

Over the past few months, the pediatric surgeon has been “saving up” hypospadias cases for this workshop, so we had about 100 patients in-house to “choose from”. The residents decided on about 35 cases that were challenging in different ways, and those were the target to finish during the three days of surgery. About six cases per surgeon per day was a pretty aggressive goal, but the gauntlet was thrown down. Below is part of the team hard at work:



I'll spare the details, but the ensuing three days were very interesting and a great learning opportunity. Since the whole goal of the workshop was teaching, the surgeons basically talked throughout the cases, explaining each and every detail, their thought process, etc, which is awesome as a student. I got permission from the head of the hospital to participate, so I was also able to scrub on some of the surgeries when the Kenyans residents and students were otherwise occupied. I probably saw more hypospadias repairs than I'll see in the entire 5-6 years of my residency; I'm definitely fortunate that I had this opportunity. Here’s me deep in thought during a surgery:



I've been in the OR a fair bit since arriving in Kenya, but this was the first time in a developing world OR for the visiting surgeons. Though they were generally patient, I definitely heard more than once, "I need scissors that cut!". Not an unreasonable request, but sometimes more difficult to find than you'd think.

Kenyatta National Hospital

At 8:00 the next morning, a driver from the hospital picked us up (the two urologists and me) from the hotel (where they were staying. I'm in a much cheaper, but quite cheery guesthouse). The hospital was only a five minute drive away.

Kenyatta National Hospital is the largest hospital in East Africa, and until a larger one was built in Johannesburg, it was the largest in Africa. Built by the British (like many large structures in Kenya), it was actually called King George VI Hospital before independence and was renamed for Jomo Kenyatta, the first President of Kenya. KNH is the main teaching hospital for Kenya's medical students as well.

We were met by Dr. Kanyi, the urologist in charge of the week’s workshops. We then B-lined to the office of the “Med Supe”, or head of the hospital. Here, we were presented to the Med Supe, and he welcomed us to the hospital and gave us permission to work there. We then posed for a photo op, which will probably end up in the IVUmed newsletter, and maybe some Kenyan newspaper. I’ll be on the lookout. I have then take a few shots with my camera, but they all came out extremely awkwardly.



Dr. Kanyi walked us to the ward where the patients awaiting surgery were staying. It was a big room with many beds lined up along the walls, probably about 50 beds in all, with a few tables for nurses right in the middle. Though it looks cramped, it’s actually much roomier than the wards in Msambweni. Mothers and their boys arrived over the weekend, and they’ll stay here through the week waiting for the surgery, and beyond during recovery.



Though things were on a much grander scale at KNH than the hospital in Msambweni, many things were similar. The buildings are in similar states of disrepair. Once structures are built here, I don’t think maintenance or renovation is ever considered, so there are a great many buildings that were once nice, and could be nice again, but money to do the renovation can never be found. The wards are similarly arranged, and primarily run by nurses, though I did notice that doctors visited a lot more frequently. Finally, waiting lists for surgeries is very long, with many patients waiting a year for elective surgeries.

Stay tuned for some surgery action tomorrow!

Nairobi News: Meet and Greet

I arrived in Nairobi on Sunday at around noon for the urology workshop and conference that I mentioned in my previous post. My lovely wife was holding down the fort on the coast, as it was already a financial stretch to have me stay in Nairobi for a week, and she's actually been doing some pretty important work in the lab lately (thanks, E!).

The first order of business? Go to the secondhand market (Toi Market) and get some "nice" clothes for the week. Kenyans are quite formal; men nearly always wear slacks with a button-down tucked in. It's usually ill-fitting or well-worn due to it's secondhand-edness, but the spirit remains. I wasn’t expecting to attend any medical conferences while here, so I didn’t bring anything too nice. Anyways, I tried on about 50 pairs of pants at Toi Market, and finally found two winners. Not bad for $10.

In the evening, I had arranged to meet with the urologist from Stanford at his hotel, so we met and drank a beer. Soon the urologist from Switzerland joined us, and I then learned that there was actually a welcome reception at the hotel for us that evening. I had fortunately opted for the khakis and oxford over the jeans and rugby that I strongly considered.

The welcome reception was a small gathering of about 10 urologists from around Kenya (mostly Nairobi), and we just had some "bitings" and drinks. I had met or talked to a few of them before, but others were a little confused as to who I was, as only two pediatric urologists were to attend this workshop. I explained that we lived here, and that I was technically a member of the same urology organization, but they didn't specifically send me here, but I was excited to learn. This explanation of me showing up at their conference seemed to suit everyone just fine, and conversation shifted to things which interested them more, specifically my height. We retired after a few Tuskers to rest up for the next day.

I must say, I was a little apprehensive about the workshop and conference week, as I had literally no details, but Day 1 went smoothly and I was really looking forward to the coming week.

Child's Play: Copying Mom and Dad

A blog about school even though I haven't been there for a while. I miss the kids and found watching their free playtime to be incredibly interesting.

I minored in psychology in college so I have taken a few classes on child development, etc. and one of the things they often say is that children learn by imitating adults. Children copy what the adults are doing and this is the way they learn the spoken and unspoken rules of their culture.

This rapidly comes into focus when you change cultures and see children doing things that you'd never see in the US. For example, the kids at school play matatu. They line up chairs very close together and someone is the driver and someone is the conductor (the person who collects the money). The kids even shout "ferry, ferry, ferry" which is how the matatu conductors in Ukunda signal that their matatu is headed for the Likoni ferry.

This little girl is playing "house":


You see in Kenya, they make brooms out of straw or branches to sweep the areas in front of their houses. Even though this area is usually dirt, they are clearing it of rocks and larger debris. I have to admit, it does make the entrances to the homes look nicer.



See how she's bent over using the broom? This isn't the way an American would do this task but it's rapidly apparent why she does it this way if you observe her surroundings. Women in Kenya bend 90 degrees from their waist when doing tasks like sweeping, washing, or planting. They train to do this from a young age with their play and their chores. After observing this, I attempted to do our laundry standing up and bent 90 degrees, let me tell you, I have not adequately trained for that. I couldn't walk normally for 3 days afterward.

It's not just the girls though. Little boys walk around and swing sticks side to side at the ground practicing the way their fathers clear land with huge pandas (very, very sharp knives about 2 feet in length).

When they play with dolls, they don't hold them in front of them like an American child would. They tie them to their backs with sweaters so they can "wear" them like their moms wear their younger siblings.

See how Yasmin has the baby on her back:


I have never seen a Kenyan child hip-carried like an American child. The mom's have to walk much further distances so they wear them strapped to their backs. In fact, the children actually learn to balance by the time they are about 10 months old and they don't even tie them for shorter walks. The other day I had one child, Ryan, on my back and managed to bend down and tend to the skinned knee of another child and then stand back up all while Ryan just hung on and balanced. I never even steadied him, he just knew how to hold on.

You can learn a lot about Kenyan culture and customs by watching the children at school when they play make-believe. It makes you wonder what a Kenyan dropped into an American school would notice.

Pippetting in Kenya

As M previously mentioned, I am helping out in the lab for a few weeks so we don’t overwork the Kenyans. Working alongside Mzungu has been interesting to say the least. First, notice his name? Yes, his given name is the exact same word as “person of European descent” that people constantly yell at us. Why you would name your Kenyan child, “person of European descent”, I have no idea but it sort of rounds out his oddities so I guess it makes sense.

Despite having an excellent command of English (including lab terms), Mzungu rarely does more than grunt when you speak to him. In fact, he’s perfected the non-response to the point where you’re often not sure whether he has heard the question. The hilarious thing is that despite uttering about 25 words a day directed at me in the 8 hours we spend together, he actually speaks to me significantly more than the other people in the lab. The other men in the lab enter every morning and greet only M, asking him about his health, his sleep, and making pleasant morning conversation. I think I’m adapting to Kenya because M noticed that they don’t speak to me, I didn’t even register this fact.

Mzungu is a trained laboratory technician but he does not, under any circumstances, multi-task. He was thoroughly horrified that I was labeling the next set of tubes the first day while the samples were spinning in the centrifuge.

“How do you know how to label the tubes” he exclaimed
“Well I was copying them from your log book and then I double-check them when the samples are done spinning”
[Furrowed brow, no further comment]

He spent 2 full days this past week watching my every move with the pipette. After the 15th hour over 2 days, I asked him if I was doing it ok or if he had any suggestions. He shook his head. I asked if he wanted to take over and he again shook his head.

“Well, I think you can probably do it faster than me and I feel badly that I’m not saving you any time since you have to watch me so let me know if you want to do it”
[Quick scurrying away, no further oversight from him, luckily M's lab advisor is here and I'm doing it fine]

The end of the experiments involves plating all the samples and then applying different antigens to see whether or not the baby is making the correct antibodies to infectious agents. You can plate 2 samples on each plate so I usually make 3-5 plates per day. 90% of what goes on each plate is the same since the process is standardized. The only thing deviating from plate to plate is the sample of the baby’s blood. Given this 90% continuity across plates, I typically plate the samples one by one but then add the first antigen to all the plates before moving on to the second antigen, etc. This allows me to be efficient and not to have to open and close plates and antigens constantly. Mzungu watched this whole process silently before just shaking his head.

To be fair, I’m sure he’s concerned that I’m being accurate given the importance of processing these samples. I know, however, that this organization is actually preventing me from making mistakes since this is how my brain is organized. Also, it’s kind of ironic to be concerned about quality control when you were so concerned that you had help in the lab that you allowed me, an untrained biotech consultant, to take on 50% of your job. In the past, they’ve had 2 Kenyans [Mzungu + 1 other] do this job that I estimate takes me roughly 4 solid hours plus Mzungu’s 3-4 hours. For those of you playing at home, that’s eight hours of actual work but it’s important that the lab people don’t feel overworked and walk off the job during the all important follow-up appointments for the babies or the lab loses all its data.

The upside is that I also am able to help M with his experiments every morning. Plus, we get to blare country music and watch Mzungu make faces about how terrible it is, and that is totally worth it.