A SPECIAL PATIENT

A few months back a patient walked into my office frail and weak. He had come to pick his biopsy results for a suspicious growth. He had come in with his relatives; son, daughter and handsome grandson. I don't know why I took a liking to these strangers. Either it was the charisma and high spirit of the mzee or the non-Sumbua (non-fussy) nature of the relatives. We clicked !! I talked to them for a while, made them comfortable then slowly broke the news of the diagnoses. It was unfortunately the 'C' word. The 'disease' was at an operable location and I immediately knew that a trial of surgery was a viable option.

I never really get very involved with patients but for this special man, I went all the way. I privately talked to the surgeon (a visiting surgeon from Italy) and we agreed that there was no harm in trying as long as the tumor was localized. Again I gave it my all in doing the labs and the necessary radiological examinations. To cut the story short, a decision to try the surgery was made but there was that risk of local involvement of local structures by the tumor which was difficult to visualize on radiological examinations. I explained this to the relatives and they agreed to try it instead of doing nothing.

Surgery was unfortunately 'short' (lasted for only 20minutes) because we discovered that it was unfortunately too late. There was extensive local spread. Nothing could be done!! It was a matter of 'open, see and close'.

I met with the family the same day post-op and broke the news to them and again they were very understanding. I discharged the old man 4 days later and referred him for hospice palliative care. It was too late to even try chemotherapy or radiotherapy. The days we had him at the hospital were happy days because he would crack the other patients with jokes and stories.

I kept tabs on how the old man was doing and this past weekend, I did what I never do. I decided to pay him a home visit. I learned that he had to get weekly intravenous fluids due to dehydration episodes and I decided to spare him a hospital visit by buying I.V fluids, branula etc and do it for him at home.

He was extremely happy to see me and we had a chit-chat as the fluids run into his veins.  He was having some brief episodes of confusion but I went a long with the mildly confused talk. He got very energetic and even stood and walked outside later that evening. I left him a content man with a big smile and he blessed me just as I was about to leave. I promised to visit often but little did I know that this would be my first and unfortunately last visit with 'Mr. Charisma'.

His grandson did call me today and informed me the Mzee had gone to be with the Lord. I said a short prayer for him and I'm so glad that I gave him the best  care. I'm happy I went for the home visit. I learned a lot about remaining positive from this man and I pray that his soul rests in perfect peace. AMEN!!

MY EXPERIENCE AS A BIRTH COMPANION.

This past month I literally  got a chance to be on the other side of the table. My cousin had chosen me to be her birth companion( if you are pregnant and you haven't decided on who will be your  birth companion then you are not serious with your birth plan). I know that in most public hospitals, patients are not allowed to have companions in the labour room but it's something that should be allowed to some extent. I was excited about the honour that she had bestowed on me and I looked forward to it very much. When my entire family left the house to spend the weekend back home in Machakos like it always happens, I was a bit reluctant because I had given her my word to be around during the days approaching her E.D.D. (Note,a mkamba doesn't sleep in Nairobi on a Friday, this is a known fact; afterall Masaku NOO VAA!!)

I am an avid fan of all pregnancy related shows on TV like 'One born every Minute', 'I Didn't Know I Was Pregnant', 'Adventurous Deliveries' e.t.c mostly on TLC Dstv Channel 172 ; so I had an idea what birth companions go through.

The much anticipated phone call came in on Saturday at 8.00a.m and I was super excited. As a medical doctor, I get very irritated when patients come in with their 'medic relatives' who know it all and want to control everything so I knew that I had to play this very cautiously without crossing other medics  borders.

In the hospital where she was delivering, only the spouse is allowed into the delivery room but I gladly convinced them that I was stepping in on behalf of the spouse. Ofcourse I was a bit anxious not to let anything go wrong because I'm not sure if I would ever forgive myself, there's a sense of responsibility that kicks in when you are watching over your relative. We were in the company of her amazing friends but unfortunately they wouldn't be allowed in for as many hours as I, the 'spouse.'

I humbly introduced myself to the midwives and the 'Intern' (he was either a doctor intern or a very experienced nurse). I played it dumb and cool ; back in my mind I kept wondering if they knew that I practically run the maternity in my hospital and all decisions during working hours fall on me. They must have thought that I was meek and docile ; and that was excellent because I didn't want to intimidate anyone.

I noticed a few mishaps here and there that I would ordinary ignore but not with my cousin.  I literally kept bugging them in a friendly and flattering  manner until they did the correct things but without feeling pushed and intimated.

Again, my hand was sore from all the lower back massaging. At one point I would be told I wasn't rubbing the back adequately and at the other time I would be told I'm rubbing it too much; they are called women in labour, they are allowed to command the moment, haha! I also forgot to eat or drink anything till around 5.00pm when my cousin's friends brought me something to eat and I devoured it irregardless of the maternity environment. I thought I looked mean eating infront of an exhausted labouring woman but I reminded myself that I needed the energy to focus on the task ahead.

I was also very keen to feed her often and give her energy drinks so that she would have adequate energy when the time for pushing out the baby would come.


There are moments she caught me laughing at her but hey, the dramatics of a labouring woman can be comical. I'm sure every woman smiles over some of these memories. I also assigned myself the role of chief-photographer. I thought that she would want these life changing moments captured . I made sure I only took photos and videos with her phone and never mine to maintain privacy. I believe these are very intimate moments that only belong to her and her soon-to-be-born child.


When I felt like she wasn't being monitored adequately as need be, I would call the pretty nurse and request her to politely do what was needed, and we bonded well. I refused to enter the examination room as they did invasive examination because I didn't want to cross into another doctor's territory and I also respected her privacy.

Of course I have dealt with many pregnant women and I know when they are psychologically feeling things. When my cousin would tell me that she was at the point of pushing the baby, I would just sneak out and come back pretending that I have alerted the doctor. Of course you don't bear down so early until you reach a certain dilatation. This happens to us doctors a million times so when you tell your doctor that you feel like pushing and he ignores you, trust me he has your best interest at heart.

We laboured till evening and we reached a point where action (caesarean section ) was needed. I being a staunch supporter of Vaginal Delivery made sure we tried it fully but of course without putting the baby at risk. I would hate it to go home thinking that I contributed in unnecessarily rushing to a Caesarean Section. I had literally forewarned her not to mention the word Caesarean-Section infront of me because I was hoping that she had it the 'normal way.'  I had a partogram( a graphical monitor of labour) in my head, literally and I knew it when it was time to go to theatre. I anticipated a malpresentation, but behold it was a big baby coming out of what looked like a very small pregnancy bump; that caught me off guard literally. How could we have missed out on a Big Baby diagnosis? We had all relied too much on a scan done the previous week which had estimated a fairly small size baby.

In the labour room, I was able to calm down a husband who was very tense. He sensed that I was abnormally calm and he approached me for moral support. I did open up to him that  I am  a medic and with that, gave him the avenue to ask as many questions as he wanted to calm him down. They had lost their first baby at birth and were still traumatized and hoping they would be successful this time round. He managed to calm down finally and be strong for his wife who was clearly going through a difficult delivery. I realised that probably God was using me to wipe off fears from this family in my capacity as my cousin's 'spouse.'


I exited the birth companion role and entered the 'grandmother' role. I was alone at the bedside at the Post-Operative ward waiting for mother and child to come back from theatre. Those were long, tension packed hours. I expected them out in 45 minutes to 1 hour but they took a whole two hours. I kept re-assuring myself but as a medic, I kept going round and round on all things that could go wrong. Soon, I had the pleasure of being the first to hold and clothe the big baby together with the nurse as we waited for the mother to be 'sewed up'.

I would have jumped in to help if anything went wrong, whether with permission or not; I'm I not a licensed doctor in the country? This reminds me of a doctor friend whose child developed breathing complications immediately post delivery and she hastily jumped out of bed with placenta dangling in between her legs and resuscitated her child. By the time the doctor arrived, her child was sorted.

I left the hospital late in darkness but went home a very satisfied woman. Of course I carried home lots of my cousin's DNA, in form of amniotic fluid,  blood, tears etc in my clothes but those were marks of success and victory.

This task made me give a lot of respect to spouses who go through it all in the labour rooms. It's not easy sitting on that bed for more than 12 hours observing a loved one suffer. It's for the persistent, patient and strong at heart.

It also made me appreciate the importance of having a birth companion. I'm a medic and I know that patients who are accompanied are usually taken more seriously.

I also learned the importance of respecting colleagues when in their territories. The midwives loved me to the point of sneaking a joke or two when I went to enquire anything. The maternity guard(Askari) also liked me and praised me for my persistence till I had seen the end of the delivery.

I also learned to treat patients with utmost care because for us, it's an everyday job with 'objects' to treat, but to a patient, this is the first time in their lifetime to ever go through an unforgettable experience. When a doctor spoke harshy to my cousin, I was hurt, yet I do use such words frequently in maternity. For example, I don't like being touched by a labouring woman when doing a vaginal examination yet it's a painful procedure that they have probably never encountered in their lives. With this, I have become a more compassionate doctor especially in maternity.

I pray that my cousin Jacinta and her beautiful daughter have an amazing life together, full of wonderful memories and friendship.

'Dear Jacinta, should you require a birth companion for another pregnancy, I'm all yours. Thanks for trusting me with this very important role.'

BLIGHTED OVUM

             BLIGHTED OVUM
I have been spending so much time with pregnant women of late such that my body, soul and spirit is in pregnancy-mode, I'm actually awaiting my 'first delivery' 3 days from today.  2 close relatives and a best friend are pregnant so I have been bombarded with lots of pregnancy questions. One of the questions that has always come up is about a formed pregnancy with no baby (embryo). This might sound very impossible but it’s a frequent phenomenon. My patients look at me in disbelief when I tell them that they are indeed pregnant but with no baby forming. I have had to take them step by step on the ultrasound till they get it. In the hospital I work in, I see at least two cases weekly. For those who don’t believe the diagnosis, we always advice them to repeat the ultrasound after a week or so, or get a second opinion for the sake of psychological satisfaction.



WHAT IS A BLIGHTED OVUM?

A blighted ovum occurs when a fertilized egg implants in the uterus but doesn't develop into an embryo. It is also referred to as an anembryonic (no embryo) pregnancy and is a leading cause of early pregnancy failure or miscarriage. Often it occurs so early that you don't even know you are pregnant. The pregnancy appears normal on an ultrasound scan in its early stages, but as the pregnancy progresses a visible embryo never develops or develops and is reabsorbed. In a normal pregnancy, an embryo would be visible on an ultrasound by six weeks after the woman's last menstrual period.

WHAT ARE THE CAUSES?
The causes of a blighted ovum are often due to problems with chromosomes, the structures that carry genes. This may be from a poor-quality sperm or egg. Or, it may occur due to abnormal cell division. Regardless, your body stops the pregnancy because it recognizes this abnormality.

 For most women, a blighted ovum occurs only once in their lifetime but I have seen a few women getting it twice or thrice. It becomes very depressing for some.

WHAT ARE THE SIGNS?
With a blighted ovum, you may have experienced signs of pregnancy. For example, you may have had a positive pregnancy test or a missed period.
Then you may have signs of a miscarriage, such as:
• Abdominal cramps
• Vaginal spotting or bleeding
• A period that is heavier than usual.
If you're experiencing any of these signs or symptoms, you may be having a miscarriage. But not all bleeding in the first trimester ends in miscarriage. So be sure to see your doctor right away if you have any of these signs.

HOW IS IT DIAGNOSED?
An ultrasound test is usually needed to diagnose a blighted ovum -- to confirm that the pregnancy sac is empty. For diagnosis, the sac must be of sufficient size that the absence of normal embryonic elements is established. In case the doctor is doubtful, he can recommend one extra week of observation followed by a repeat scan to be sure of the diagnosis once a sufficient size of sac is achieved.

HOW TO TREAT IT

If you have received a diagnosis of a blighted ovum, discuss with your doctor what to do next. Some women have a dilation and curettage (D and C). This surgical procedure involves dilating the cervix and removing the contents of the uterus by curetting. Because a D and C immediately removes any remaining tissue, it may help you with immediate mental and physical closure. It may also be helpful if you want a pathologist to examine tissues to confirm the reason for the miscarriage.

Using a medication such as misoprostol ('the white tablet') to stimulate the uterus to expel the contents may be another option but this must be strictly done as an inpatient in case bleeding complications arise. However, it may take several days for your body to expel all tissue. With this medication, you may have more bleeding and side effects. With both options, you may have pain or cramping that can be treated.

Other women prefer to forego medical management or surgery. They choose to let their body pass the tissue by itself. This is mainly a personal decision, but it must be discussed with a doctor. I remember almost losing a patient who decided to wait for the body to expel but ended up getting life threatening bleeding and ended up being rushed to theatre for an emergency D&C and had to have urgent transfusion.

HAVE I EVER SEEN A NON-DEVELOPING EMBRYO??

I remember doing a D&C and of course after almost rupturing the amniotic sac on my face, the small embryo came out. It was so small, about 3 cm long, I put it aside to study it after the D&C but of course it had melted into a white matter by the time I was done. This fascinated me.

I hope this post was educative enough and I hope that Doctors also stop telling patients 'mimba imeharibika na lazima uoshwe' (pregnancy is spoilt) instead of explaining the exact nature of the condition that made them miscarry and telling them all the options available for them.

Have a fruitful week!!!

A DAY IN COURT

A day in court

I did get a court bond to appear as a witness in a case. Working in a private mission hospital, I thought all along that the job of appearing in court only applied to doctors working in government hospitals. I had to go, skipping a bond can call for a warrant of arrest. I had been called upon to attend court cases before as an expert witness and never had to testify because the cases would be moved to other dates due to unavoidable reasons. My work would always end at the prosecutors office and not at the court house.

I left my house at 7a.m, so that I can be in court at exactly 8.00a.m. I guess I was being paranoid, Kenyans don't really mean the actual time they indicate in the particular summons and memos. I realized that I had arrived an hour earlier than all officers working in the court. So I burned time in the car browsing the internet for more than an hour and regretting why I had not left late after completing a ward-round.


At around 9.30a.m I entered the court house and yap, sat on the wrong side meant for prisoners and offenders and one police officer politely informed me to move to the opposite side. The court was packed to capacity, at one point I thought that I was in a packed Chaaria Probox Matatu. We were all squeezed in together.

I thought court was a very serious affair. I had previously attended court at Milimani Law Courts in Nairobi in which the Grand-Mullah was a lawyer to one of the parties( I don't know law jargon so forgive me). The court was conducted in a very serious manner and I didn't understand a word in that particular case because it was all about 'mentions', 'petitions',  millions of shillings in bond etc.

Back to this court, the judge entered and we all stood as per protocol. Did I mention that the judge looked quite handsome and neat?(I might get divorced for mentioning this, haha). I was so respectful of the house of justice, so I sat quietly at the back,  switched off my phone and was careful not to cause any noise, even a cough. I didn't want to be 'thrown in' incase my phone rang.

The judge started going through the files calling each offendant ( are they called that?). There was a lot of comic and laughter in the cases. Here was a judge, who knew all common petty criminals by name, character and their common offenses. He would even bring in a joke in Kiswahili or Sheng' and this made me relax.  The same way I know my 'regular patients' by heart, is the same way he knew his 'boys and girls.' At one instance he send a police officer to call one lady he had spotted loitering in the compound because he knew she would definitely be linked to one of the cases of the day because she was a 'regular'; and behold she was indeed involved.

A lot of the cases involved sale of alcohol without license, illicit brews business etc. 50% of the criminals were actually minors, to my shock and surprise. My case was called out and I stood, excused the court, introduced myself and politely asked if my case would be heard first as I was needed at work.

The judge was very very polite, he told the rest of the court to take a break as he went to hear my case in his chambers. We went in, I swore by the Quran. I was very uncomfortable to see a non-Muslim carry the Quran to bring it to the chambers. There are purity and cleanliness protocols to be observed before one can hold the Quran, which I'm sure they had not observed or were not aware about them; ignorance of the 'Quran protocols' is no defense.

The case proceeded well, cross examination was done on me which put me at an uncomfortable spot. I'm not used to confrontations. I was excused to leave immediately after my testimony(is it called that?). On my way back to work, I kept on wondering if I had given my all,if I had given the evidence to the best of my ability to ensure that justice is served. Again, it related well with my work. My paranoia and quest to do the best has sometimes made me go back to the hospital very late at night   just to make sure for example, that I have not left a tourniquet on a child's hand that could cause gangrene. Of course all the time it ends up being just paranoia. The driver kept asking me details of the case and I reminded him that my profession demands confidentiality at all times, even when outside the hospital.

Of course I swore never to attend court again because I live in a village where everybody knows each other. I'm afraid testifying against some people could put my security at risk, one has to be very careful when dealing with Murumes. Because of this I called the police officer involved and told him to never ever link me to a case involving issues in my locality. (Sometimes I feel like Santalal- the doctor actor in the Series 'Santalal' at Citizen TV).

So Judges, lawyers, police officers are just like doctors in so many ways. They do exactly what we do. I saw the judge writing down 'history' notes and I realized that we are not the only ones who write notes.  I'm sure they sometimes lose sleep due to work issues just like us. Law was always my second choice after medicine and I wonder what kind of a lawyer or magistrate I would be!

LESSONS LEARNED FROM RAMADHAN- THE HOLY MONTH

LESSONS LEARNED FROM RAMADHAN

1). TO BE A GOOD TIME MANAGER....

Ramadhan has taught me to be an excellent time manager. The 5 obligatory prayers plus many more prayers have to be prayed in this holy month, some in the middle of the night or very early before 4a.m yet we are still expected to do our service at our places of work with utmost diligence because diligence at work is also a form of worship. We also expected to read the Quran as much as possible and do dhikr(devotion).The trick to this is being a good time-keepers and planner.3 Sleeping time has to be pre-planned and pre-calculated to fit the schedule, no more wasting time lazing around, T.V time is strictly for news only and Islamic channels because the time is very minimal, traveling has to be pre-planned to fit prayer schedules at different mosques on the way e.t.c. 24 hours are so less.

2). IBADA(WORSHIP) INCLUDES GIVING MY BEST

I can't afford to be harsh to anyone or treat a patient half-heartedly because giving our best is considered a form of worship which is very crucial in life and mostly in this holy month. Hurting someone could make ones fast null and void. Giving substandard services yet you are drawing a salary could be considered sinful.

3). INTER-PERSONAL SKILLS ENHANCED

My communication skills and relationship with my colleagues has greatly enhanced. I have to be careful how I talk to people to avoid hurting anyone, there is no space for talking ill or complaining about anyone, I have learned that direct, firm yet friendly confrontation is the best approach.

4). ALL MY SENSES ARE IN FASTING MODE

EYES- I can't watch things that are detrimental to my spirituality and personality. Islam teaches us to lower our gaze even on the roads.

EARS- listening to gossip, unnecessary talks, bad music etc is a NO NO NO ( not that I listened to these before anyway!)

MOUTH- what comes out of my mouth should not hurt anyone but should instead be a  blessing to them and if possible be in the path of worshipping Allah in one form or another.

5). THE ART OF GIVING.
The whole idea behind fasting is to be able to give back to the society. Nobody slept hungry or suffered because of giving to the less fortunate. Giving should be as secret as possible because giving is not meant to be for show-off but for the sake of Allah. The Quran says that what the right hand gives, the left hand should not know about it.

6). MODESTY
Ramadhan has a way of drawing people back to being modest. Modesty in form of ones behaviour, dress-code, talk etc. People might judge but that's one of the purposes of Ramadhan, to draw people back to their creator.

7). IT'S OKAY TO 'UGLY UP'
I am rocking dark eye bags and I'm proud of it. If we can trans-night studying to pass exams or do crazy night calls in the hospital , then surely we can sacrifice for Allah; waking up very early e.t.c. I'm in constant contact with water more than the 5 obligatory times, but that's okay. Natural face with no foundation on is the way to go, so I realize.

8). HEALTHY EATING

Ramadhan has a way of 'shrinking' ones stomach. No matter how gluttonous you are, you can't eat much. A bite or two and fruits is almost always enough. We are also prohibited from eating much Iftar so as to remain light during the long taraweh prayers.

9). HUMILITY
Ramadhan has a way of humbling us. We all become equal. A rich man and a poor man go through the same pangs of hunger, the same prayer sessions, etc. Ramadhan is an equalizer in it's own right.

10). TOLERANCE
If you can tolerate pangs of hunger with a happy face, then trust me you can tolerate anything. I have realized that  when treated badly I let it pass unlike in the past where I would whine, hurt, complain etc. There's just a tolerance and peace that comes with Ramadhan that I can't explain.

Sometimes I wish that each of the 365 days of the year was Ramadhan. The joy and peace that comes with Ramadhan is amazing. Everything is always in synchrony worshipping Allah. It's the time of the year when we all get to drop any vices and  go back to God fully. I pray that Allah gives us grace to make each and every day of our lives Ramadhan; Amen!! Ramadhan Karim

WORKING IN COTTOLENGO MISSION HOSPITAL

My experience in Cottolengo Mission Hospital Chaaria


I remember one evening when I was having dinner with younger colleagues in Meru during a KMA meeting, one of the colleagues causally said 'The doctors in Chaaria are quacks.' I was so hurt and shaking from head to toe in anger . I took it so personally and gave him a piece of my mind. I almost shed a tear, I didn't know that I had come to own Chaaria that much. I asked him to go ahead and give me ten reasons why he had generalized Chaaria to be a substandard hospital; he couldn't point on any single reason despite thinking hard. My final conclusion is that he had inherited that ideology from his seniors. He had never been to chaaria, couldn't point at any single patient we had mismanaged yet he had gotten used to the ideology that Chaaria must be substandard because the prices are too cheap. I feel very sorry for the doctors who have refused to change this school of thought. Instead of doing blame games, we would be of much help to the citizenry by having collaborations, consultations  and referrals among one another.  My boss Dr. Gaido always tells me that our 'Big-Brother' is our patients. They still come despite discouragements from medics in town. They came from as far as Mandera and still spread word for the good job we do.

The first day I took Chaaria seriously was during a KMA meeting when Dr. Gaido announced that he was looking for M.Os to apply for locum chances. My colleagues reminded me that Chaaria was in the middle of nowhere and that no sane lady would make it to locum there. I decided to visit the hospital and keep an open mind. I remember it was a Wednesday afternoon when I made the trip, I found the OPD so full of patients and told myself that if so many patients could make it here while frail and sick then I could also make it for work. The first person I talked to was Senior Clinical-Officer Jonah Gitobu Mworia, I introduced myself and he was very helpful. He showed me a place to sit and asked me to sit and wait for the 'boss'. Dr. Gaido saw me a few minutes later and told me the he instantly trusted me due to my religion and believed that I would not let him down. As planned , I was able to work in the days agreed upon and it wasn't bad at all. While my colleagues back in Meru still complained that it wasn't humanely possible to commute to Chaaria, I was busy making an extra coin and learning a lot at the same time.

When I applied for my annual leave at Meru Hospital, I knew 45 days was a long time to sit at home and do nothing. I was also tired of working in an environment where systems where just not running. Thanks to the county health administration , things at Meru Hospital are much better now. So anyway, despite having an opening at Agakhan Meru, I approached Dr. Gaido and asked him if he could give me a 45 days locum opportunity. He gave it to me without blinking, it was such  a  relief. During the course of the locum, I came to really love working in Chaaria. I felt that I belonged there. The satisfaction of helping a very poor patient get 1st class health service at a near zero cost was immense. I did the unimaginable among young doctors and decided to apply for a long-term secondment opportunity. Many people called and discouraged me, I was going to get cut off from civilization , that's what they told me. 8 months later, I'm so glad I took the plunge. I'm definitely not the same Khadija. My life has changed, I have gotten so much experience, I have gotten so exposed by working with professionals from Italy, Poland,Britain, Canada etc.

Chaaria is the only mission hospital in Meru that never turns away anyone because they cannot afford admission fees. Service to the poor is really the mission here. We have done major surgeries for patients knowing very well that they wouldn't afford the bear minimal of the cost but we have done what we have to do to save their lives.

I remember one instance, my friend from Meru brought his sister to have a kidney stone removed. The minimal cost he had been charged in Nairobi was 500,000 shillings. I called him and told him that he would pay nothing if he had a NHIF cover. He couldn't believe it. He asked me a few questions just to clarify if it was standard surgery. I reassured him. Because his patient was not covered by NHIF, he paid a total cost of KShs. 6,500 and surgery was successful. Since then he has been a good ambassador to us. He is one man that shuts down those that call us substandard because we are too cheap. Kenyans must change that ideology that cheap is fake. If an organization wants to help, don't start doubting it for being too cheap. Another thing is that our buildings are not as posh,  but would you rather be in a posh building and get substandard yet costly service or be in a standard simple room and get 1st class service at a low cost???? Food for thought.

When I asked Dr. Gaido to teach me how to do Hysterectomies, I was scared, I didn't know what to expect. I had been in a system where no one would dare teach you something major for fear of you bringing competition in the private sector. He was very happy with my new interest and taught me very selflessly and patiently. I'll forever be very grateful to him.

One of my patients told me that in his opinion, Chaaria was the prime Cancer Diagnostic Centre in Meru and that I should look for Hon. Julio Mbijiwe and show him our cancer registry and challenge him to ask the County Government to facilitate a monthly visit by an oncologist at Chaaria. I was touched by this view.  The patient had visited the Oncology clinic at Meru Hospital and had noted that 98% of the patients there were referrals from Chaaria with referral-letters written by me. So instead of sending the patients there, why not send the doctors to the patients? I hope Hon. Mbijiwe sees this post and does something about this situation. We are the only hospital in Meru doing ultrasound guided biopsies and  having an organized histopathology chain.

The road to Chaaria is terrible, totally impassable during the rains. If Chaaria sees a net of 150 patients per day despite the bad road, can you imagine how many more patients we would help if the road was tarmacked. I implore the County Government to take the example of Machakos County and prioritize infrastructure especially if it also opens up a health facility. Hon. Munya are you listening? It just takes three months to tarmack a road 'Mutua-style.'

I could write and write, but Cottolengo Mission Hospital Chaaria has changed my life in so many ways and I'm very grateful for the opportunity to work here. I don't take it for granted. My ideologies have changed, I have become more tolerant and patient, but above all, I have become a better clinician with so much experience that my colleagues can only envy.

ALCOHOLISM AMONG POST-MENOPAUSAL WOMEN

Alcoholism among post-menopausal women



It would surprise you to note that many of my 'above-50' female patients are chronic alcoholics. I'm following quite a number for Liver Cirrhosis secondary to alcoholism. I see their daughters cry when they open up to me about their mothers drinking behaviour and how they had tried to no avail to help them quit drinking.  I have also admitted quite a number in alcoholic coma; drinking till someone passes out completely.

All these women have many things in common. All are above the age of 50, all are widows and only started drinking after the passing of their husbands, all have inherited quite a lot of property and land, all have extremely responsible and well behaved daughters who bring them to hospital and wash them when they pick them from the streets(meaning they were extremely responsible mothers during their productive age).


So what makes them develop this disturbing behaviour? Is it the freedom that suddenly comes with the passing of their husbands? Is it the unlimited control of inherited property? Is it in course of countering the stress that comes with body changes in menopause? Is it the increased loneliness that comes with losing their spouses?Or is it just a mid-50 crisis among women?

I researched on this online to satisfy my curiosity and also to understand my patients better.

The hormonal changes occurring during menopause may lead to uncomfortable emotions. The woman may also have many concerns and fears about what is happening to them such as:

* It is common for women to feel sad because their child bearing years are coming to an end. For many women this will have been an important aspect of their identity

* Menopause is a reminder to women that they are getting older

* The woman can feel less attractive because of the things happening in their body

* They may worry that their low libido due to menopausal changes is going to be permanent

* It is common for women to become easily irritated

* They may feel excessively nostalgic for their younger days and younger bodies

* Women can feel anxious because their body is doing things out of their control like hot flashes and temper fits

* They may experience an identity crisis

Woman use different strategies to help them cope with the emotions of menopause. Unfortunately, some women may turn to negative coping strategies such as alcohol abuse.


So how does one deal with the change that come with menopause.
* Techniques such as meditation are great for helping people cope with stress and anxieties and it can also make it easier to sleep at night.

* Hormone replacement therapy (HRT) mainly estrogen can make a difference for people who are struggling with the symptoms of menopause.

* Night sedatives like Piriton  may help people sleep better at night

* Some women may need to begin taking antidepressants if their symptoms are too disruptive. They will need to speak to their psychiatrist or psychologist for this.

* Regular exercise and walking can improve mental and physical symptoms.

* Avoiding spicy food and hot beverages may lead to a reduced incidence of hot flashes.

* Having support groups with their agemates going through the same phase can be a good coping mechanism .


I hope this post helps to highlight a common problem in our society that we have not been keen on. I hope it will help a struggling postmenopausal lady or help the rest of us in the future when our golden years come. Let me know what you think!!!

WHAT WOULD YOU DO???? DILEMMA!!!!!

WHAT WOULD YOU DO? I know that I have been away for a while but I was away in my own world in a journey of self-actualisation, career concentration and personal development. I have been through a tirade of scenarios while dealing with my patients that have put me in a dilemma and made me wish not to ever be personally in such situations. Mostly we take life for granted and presume many things. There comes a time when you find yourself at crossroads and unable to choose what path to follow.

 1). THE AZOSPERMIC PARTNER. Azoospermia is a medical condition in which a man has no spermatozoa at all in his ejaculate fluid. It is mostly irreversible and is a cause of male infertility . I handle such cases atleast once fortnightly. What would you do if found yourself in such a situation? Do you involve the young wife in breaking the news? If you do so, don't you risk having her disrespect her husband and tell everyone in the society putting the man in emotional turmoil?(Remember this is Africa). Isn't it her right to know what is causing infertility in the union and save her from the mean pointing fingers of in-laws? Do you tell the wife and hide it from the husband so that she can secretly look for a child elsewhere and save the marriage?(this only happens in Nigerian movies and is unethical). I have heard cases of men committing suicide due to the stress they go through when their wives 'spread the news.' This is a very tricky situation and I have always tried to handle it with utmost wisdom, privacy and maturity. I let the man do the honors of breaking the news to the wife but I'm sure many of them end up not telling them. A young lady followed me the other day and demanded answers on why I had told her to leave the office and talked to the husband alone. What would you do, as a doctor and as the patient?


 2). CANCER IN PREGNANCY. What do you do if you get a patient who has been looking for a child for many years and when she finally gets pregnant she also realizes that she has cancer. Does she carry her pregnancy to term and postpone cancer treatment or does she disregard the pregnancy and carry on with surgery and treatment. If she disregards the treatment, won't the disease be too advanced in 8 months? If she carries on with treatment, what if she doesn't get another pregnancy? WHAT WOULD YOU DO?


 3) PRE-CANCEROUS CERVIX AT 30 YEARS
 A lady comes in,quite young with an abnormal pap-smear result for pre-cancerous condition . Recently married with only on child. What do you do? Do you do cone-excision of the cervix or remove entire uterus and cervix. She is scared of the condition converting to full blown cervical cancer and insists on Hysterectomy( removal of uterus). However, as a doctor you remind her that she is very young and might need other children or may get re-married later in life. Dilemma! Do you go ahead and do the surgery and risk her regretting in the future? Secondly what if you deny her the surgery and she ends up with cancer later on?


 4).THE HUGE GOITRE The patient who comes in with a very big Goitre causing moderate obstruction symptoms. If you don't do surgery, she might end up with severe obstruction of airway later in life. If you do the surgery, she might never wake up from the surgery due to expected collapse of the trachea. What do you do?


 5). CANCER IN THE ELDERLY I have seen relatives coming in and insisting on referrals for chemo-radiotherapy for their elderly relatives. How will chemotherapy change the life of a 95year old man with prostate cancer? Won't the effects of the chemotherapy affect the patient gravely more than the cancer itself based on their age and frail bodies? If you don't refer them, the relatives will forever blame you. But this is easy, you refer and shift the burden of blame to the oncologist.

 I hope you now appreciate what we go through. The burden of being a decision maker in matters health as well as social. The profession can really get to you. Who said that doctors are not community leaders? Have a nice week ahead. I promise more posts sooner.

ECTOPIC PREGNANCY, A FAST KILLER

ECTOPIC PREGNANCY

 On my usual patient reviews and discussion with my colleague, we went through the case of a pregnant patient who had vaginal bleeding and a regular pelvic ultrasound was done. It showed thickening of the uterus wall and retained products of conception . A diagnosis of incomplete abortion (miscarriage) was done and dilation and curretage done. The patient went home stable, her next review 2 weeks later was unremarkable and she went home happy . Four weeks later, the patient came in with sudden severe abdominal pain and abdominal distension. The abdomen was very tender to touch . And urgent ultrasound was ordered and blood was seen in the abdomen (peritoneum). The uterus was normal and non-gravid , the Fallopian tubes and ovaries were normal. So what is the diagnosis?????? Her pregnancy test remained positive all along. Further scanning of the rest of the abdomen showed an alive 4 months male fetus, with a regular heart beat and movements growing up in the intestines with placenta attached to the large intestine. The placenta had detached slightly and was slowly bleeding. A final diagnosis of ABDOMINAL ECTOPIC PREGNANCY was made and emergency surgery was done just on time and the mother's life was saved. The baby was removed alive but died shorty after due to severe prematurity.

 When I was growing up in Machakos, a neighbour lost her life to undiagnosed ruptured ectopic pregnancy. I heard the aunties say that she had lost her life to 'mimba ya mishipa' (pregnancy of the tubes) and it made no sense to me because I thought 'mishipa' only meant 'veins.' 'How can there be pregnancy in the veins?' It confused me at my tender age of 12.

 What is ectopic pregnancy? It basically refers to pregnancy that embeds and develops in other places other than the uterus. The most common location is the Fallopian Tubes followed by the Ovaries. The third and least common location is the abdomen as outlined in the first case above.

 The causes of ectopic pregnancy are directly related to any factor that causes disruption of the inner lining of the Fallopian tubes and hence delayed passage of a fertilized ovum along the tube. As we all know, fertilization takes place in the tubes then the fertilized egg travels down to implant at the uterus. The factors that cause above disruption include infections of the tubes i.e Salpingitis, chronic inflammation of the tubes as in Tuberculosis of the tubes, abnormalities of the tubes like abnormal lengths and prior tube surgeries. Research shows a high risk in patients with intrauterine copper-T devices for contraception and women who take progesterone only contraceptives. Women with a previous history of ectopic pregnancy are at a higher risk of developing a second ectopic pregnancy. 

17 out of 100 women in Kenya will get ectopic pregnancy in their reproductive life. This clearly indicates that incidence is high and that all women of child-bearing age should be armed with knowledge of this very dangerous condition yet very easy to diagnose if proper steps are taken.


 The symptoms are usually noticeable latest by 2 months of pregnancy unless in unique cases like the one above. The woman would report missed menstrual periods and severe one sided Lower abdominal pain,irregular minimal vaginal bleeding ( the pain precedes the bleeding), then severe abdominal pains. The patient may present in shock,collapsing , having air-hunger, paleness, rapid heart beat , increased thirst or even unconscious after collapsing. Shock occurs in women undergoing bleeding following a ruptured ectopic pregnancy. Most women are usually not aware that they are pregnant. A ruptured ectopic pregnancy can kill in as little as two hours.


 ABDOMINAL PREGNANCY . This happens when the embryo perforates the tube into the abdominal cavity but the amniotic sac remains intact. The embryo continues to grow and a placenta site is established on one of the abdominal structures like the intestines. Pregnancy can continue growing to term but mostly gives way and causes severe bleeding.

 I remember watching an Indian medical documentary where a fetus that had stayed in the mother's abdomen for 50 years was removed. It was actually a fetus in the form of mummified stone. This is called a LITHOPAEDION. It occurs when the fetus in an abdominal pregnancy dies, the placenta site thromboses and doesn't bleed, absorption of amniotic fluid occurs and mummification of the fetus occurs by deposition of lime salts. This can stay for many years.

 Diagnosis of ectopic pregnancy is mostly clinical through thorough abdominal and per-vaginal examination supported by ultrasound scan and a positive blood pregnancy test in the absence of a fetus in the womb.

 Treatment is usually emergency operation to remove the fetus and control the bleeding. The affected tube may be cut ( salpingectomy) and ligated to control bleeding or simply repaired depending on the severity. If the pregnancy is towards the outer end of the tube, it might be milked out if no rupture has occurred to save the tube.

 The topic is so wide and intense , I only covered a small portion and I tried to use layman's language as much as possible to sensitize people on this potentially dangerous condition. No mother should lose life to ectopic pregnancy. Spread the word and let me know what you think. Any questions will be answered promptly because I have left a big part to avoid boring you with medical jargon. If you are sexually active and get the above symptoms, seek medical advice quick before it's too late. Thank you

THE FIBROIDS MENACE

FIBROIDS

Fibroids have become a real medical dilemma especially among us career women who get into the family way very late either in the mid 30s or early 40s. I have seen patients who have come in and narrated to me how fibroids have totally messed up their lives.


So what exactly is fibroids?? Fibroids or fibromyomas are the most common tumors of the human body. They arise from the muscular wall of the uterus(womb). Their Growth is due to action of the hormone estrogen. They arise during period of menstrual activity and are mostly found in nulliparous women( those who have never had children) or women who have not been pregnant for sometime. They are mostly found in black women and  tend to favor infertility and miscarriage due to distortion of uterus cavity.


There are 4 main types of fibroids. Interstitial,Subperitoneal,Subendometrial and Cervical. This categorization is based on their locations ; within the wall of the uterus, arising from the  outer layer of the uterus, arising from the inner layer of the uterus and from the Lower part respectively. The subendometrial ones are most notorious for causing miscarriages, the interstitial ones cause abnormally heavy menstrual bleeding and the cervical ones may cause obstruction of labour during normal delivery.


Fibroids tend to grow more during pregnancy and to shrink or atrophy during the post-menopausal period.

Patients present with a wide variety of symptoms depending on the size and type of fibroids. These include;  an abdominal mass, Increase in duration and amount of menses,Offensive discharge( if a subendometrial fibroid is undergoing necrosis), Late menopause, Abdominal pains which may be accompanied by vomiting( in case of degeneration of fibroids),Frequent urination and retention of urine (if the fibroids are too big), Infertility,Frequent abortions, Labour obstruction, Mass protruding from the vagina etc.


Fibroids are diagnosed by doing ultrasound scans.  Small fibroids that are not causing symptoms do not require treatment but big or symptomatic tumors require surgical removal.  Indications for surgery include heavy or prolonged bleeding, large tumors most likely to cause urinary symptoms, fibroids causing infertility or miscarriages, fibroids that are likely to obstruct labour and fibroids that tend to increase in size after menopause( these are most likely to get malignant change) e.t.c


Surgery can either be removal of the fibroids or total removal of the uterus depending on the patients need to conceive in the future. Sometimes a surgeon can go in with intention of removing the fibroids only to end up removing the entire uterus if bleeding is uncontrollable during the procedure.


Is there a way to avoid fibroids? Not really!! Remember fibroids also run in families. We can probably avoid them by getting children early ; this way, even if fibroids eventually come         , there will be no harm in removing the uterus.


I'm not against career progress among women, but a 2 year sacrifice to get babies can help a lot in avoiding the fibroid menace and consequences.( I can hear my mother saying AMEN to this). I however agree that other factors are to be considered too.  Let me know if this post was educative.

WHEN DOCTORS LIE

This morning, I woke up to read the Paul Kalanithi story. He was a top neurosurgeon at Stanford who succumbed to metastatic lung cancer at the age of 37 earlier this month. He had written numerous essays, “How Long Have I Got Left?” for The New York Times and “Before I Go” for Stanford Medicine, reflected his insights on grappling with mortality, his changing perception of time and the meaning he continued to experience despite his illness. He closed his Stanford Medicine essay with words for his infant daughter: “When you come to one of the many moments in life when you must give an account of yourself, provide a ledger of what you have been, and done, and meant to the world, do not, I pray, discount that you filled a dying man’s days with a sated joy, a joy unknown to me in all my prior years, a joy that does not hunger for more and more, but rests, satisfied. In this time, right now, that is an enormous thing.”

 His story makes me reflect on how doctors, me included, deny patients the truth on the magnitude of their illness and the chance to prepare and face their last days appropriately. I remember the case of X who we had operated on and found that her cancer had spread everywhere in the abdomen and everything was matted together so we couldn't resect the tumor. When she came in to pick her biopsy results I told her the truth but not the whole truth. I did tell her that she had cancer but the look she gave me was so depressing and stressful that I decided to give her 'hope' and lie that we had removed the tumor and that all she would need was intervention in a cancer unit and the disease would go into remission if adequately handled. I figured out that if I broke the news as they are, depression would kill her faster than the illness. I basically left the task of disclosure to the oncologist.

 By reading the Kalanithi story, I realize that most of us deny our patients the chance to prepare for their last days. Some relatives even sneak in ahead of their patients and beg me to hide the truth and not to disclose to their patients that they have an end-stage illness. Others practically wink at me when they realize that I'm almost disclosing the disease to their sick relatives. We doctors lie in so many ways. I remember the case of 'Z' who was battling an unresectable brain tumor that was fast growing. Instead of the doctors in Kenyatta telling him the truth, they told him to go home and wait for their call on when to go for surgery. The family remained hopeful and kept on spending so much money taking him from hospital to hospital to make him 'stable for surgery' because they thought Kenyatta would call in anytime. Three months into the illness and they did not call making the patient hopeful only for him to succumb to the illness. I believe that had the truth been told, adequate preparation and coming to terms with the illness would have been made. Sometimes we even write palliative care referrals for the last-stage patients and lie to them that palliation is highly intensive treatment for metastatic cancer while in essence palliation is basically making the patient comfortable in the last days.

 Kalanithi talked about the importance of proper communication and disclosure of the whole truth in a gentle manner. His ‘dual citizenship’ as a doctor and as a seriously ill patient had taught him that respectful communication is the bedrock of all medicine. I now know and appreciate the importance of proper disclosure. It might stress the patient but with time they do come into terms with it and prepare for their illness and impending mortality adequately and with bravery.Had Paul Kalanithi not known the truth about his illness, he would have probably not planned for the conception and birth of his daughter into his illness.

You would be surprised at how strong some patients are.

The truth hurts but it is better than giving colorful lies

KCSE RESULTS AND HYPERTENSION

 Two weeks of silence. I'm back! I have been extremely busy during the weekdays and a tourist by the weekends. No excuse, I have been lazy!!!! This week, KCSE results were released. It's also on Monday that my boss and I were anxiously going through our 'KCSE' results ; our weekly histopathological reports from Agakhan University Hospital. Each batch comes in large numbers of around 20-30.  We are always so anxious to know the diagnosis of strange conditions we encounter and mostly crossing our fingers and hoping that we have less cancers. It's painful learning that certain patients indeed have cancer. My boss is  usually very anxious to know if the margins of tissues he removed are cancer-free and beaming when he learns that he did a thorough excision. You should see us seriously scruffling through the pages and commenting. For instance you would hear things like ' Oh, this is the lady teacher who came in with abnormal bleeds' or ' This is the mzee I admitted from Kangeta and I was too curios to know his progress making me pop-in in the weekends' or 'this is the father of the adamant three sons' or 'I knew it, it had to be lymphoproliferative disorder with that abnormal hemogram' etc. We quickly discuss the conditions briefly and decide on the way forward when the patients come to pick the results. The patients are usually always very anxious about the results to the extent that others literally lose weight in the days awaiting the arrival of the reports. I remember one lady was seriously shaking outside my office and I actually thought that she had urinary retention but later learned that she was too curious to know the meaning of the jargon that was written on her report. I could see a sigh of relief when I informed her that what she had was a totally benign condition; non-cancerous.  Away from 'KCSE,' today I want to talk about Hypertension. It's a condition that is becoming so common. I actually diagnosed my parents with it a few weeks back. Each day I diagnose 5- 10 people with hypertension. Of these, 8 are usually at the exact age of 55 years old. I don't know the relation between the  number 55 and hypertension.   Most of the times, Hypertension doesn't have any specific symptoms unless the blood pressure is too high. Patients present with any of the following symptoms;  persistent headaches, neck pains, blurring of vision, nausea, malaise, dizziness,palpitations, some even come in convulsing,with stroke or in a coma.  Hypertension is a paradox of an illness. Very easy to diagnose, very easy to treat and manage yet thousands of people go undiagnosed, others get sub-optimal treatment, some develop life-changing complications and others die.  Hypertension is defined as blood-pressure above 140/90mmHg in both variables or in one as in isolated systolic hypertension.  I will not go into details about how to grade it but it's graded differently depending on the values  How can we avoid hypertension? By  lifestyle modification. This involves eating low salt and low fat diet, exercising( atleast 30 minutes of brisk walking daily), cessation of smoking, reducing on alcohol use, reducing stress, managing well any comorbid illness one may have and most importantly weight reduction.Sedentary lifestyle should be avoided. We should all strive to have atleast a monthly Blood Pressure check irregardless of our age. This mostly applies to people with a family history of hypertension.  Hypertension can also be secondary to another illness. Patients with Diabetes, Renal Conditions, Heart Problems, Hyperthyroidism  etc are more at risk of developing secondary hypertension.  Medication for hypertension depend  on the grade of the hypertension. Some patients are only counseled of lifestyle modifications, others are put on one type of drug, others a combination of 2,3 or more drugs. The bitter truth about hypertension is that it's medication has to be taken for life. Its very frustrating to hear of patients who have been misguided by clinicians that their hypertension is healed and that they stop treatment only for them to come in with stroke or in coma. The doctor may reduce the number or dosage of drugs but at no given time can medication be stopped. I don't believe that herbal treatments heal hypertension, I will  leave this for further discussion.  There's no shortcut in the treatment. If not treated well, hypertension can cause complications like Congestive Cardiac Failure, Renal Failure, Stroke e.t.c One of my parents was frustrated when I told them that the medication has to be taken for life but I joked to them that probably God was passing them a signal to get grandchildren to remind them of daily drug use. That joke has become  a reality and today I celebrate the birth of AbdulRahim Mutula, my first nephew. As he grows older, may he the one to remind his grandparents to take their daily hypertension drugs.  Have a great referendum anniversary week. 

PSEUDOCYESIS - FALSE PREGNANCY

............... False pregnancy, phantom pregnancy, or hysterical pregnancy—commonly called pseudocyesis in humans and pseudopregnancy in other mammals—is the appearance of clinical or subclinical signs and symptoms associated with pregnancy when the organism is not actually pregnant. I have encountered this condition more than once and I found it very interesting. I had a case of a woman who came in for regular maternal health clinic. She looked around 8 months pregnant and she was looking forward to the birth of her child. She was very faithful in ANC clinics and had already started shopping for baby clothes. She had however come with a note from another clinician who was surprised with the 'pregnancy' because Pregnancy Determination Test was negative severally. He had referred her for further follow-up and ultrasound. I examined her and she looked pregnant. She had missed her monthly menstrual periods by 8 months, the abdomen was markedly distended( almost a term pregnancy), her breasts were discharging milk and she had Linear nigra ( the prominent black line down from the umbilicus seen in pregnancy), the 'baby' was also kicking and she excitedly grab my hand and place it on the abdomen to feel the movements. Her face was puffy like that of a pregnant woman. There were however several catches. Though the abdomen was distended, I couldn't feel the hard gravid uterus. There was no palpable fundus. The 'kicks' were actually peristaltic movements(bowel movements) confirmed on  auscultation with my stethoscope. I talked to her further and I realized that she was  desperate for a baby. I tried to counsel her on the possibility that there was no pregnancy but she reminded me that she even had morning sickness in the first trimester and the abdomen had been increasing in size slowly over the months. She believed that the previous laboratory that did her pregnancy test had fake strips.  I decided to send her for a repeat pregnancy test and an 'obstetric' ultrasound. The results came out promptly. Pregnancy test was negative and the ultrasound was a normal one with a normal non-gravid uterus. There was no baby. An abdominal ultrasound was also done just to make sure that it wasn't an abdominal pregnancy and it was also a normal scan. I took to the task of counseling her further and telling her about a medical condition called PSEUDOCYESIS. It's a false pregnancy caused by the effect of stress on the hypothalamo-pituitary-adrenal axis causing hormonal changes that stimulate pregnancy-like changes in the body. She was so stressed and desperate for a child and the brain triggered a pregnancy-mode in the body. We had a similar case of a woman who came in labour pains for a 'term pregnancy' but the midwife nurse was surprised that the cervix was  closed despite the woman having very strong visible contractions for many hours. She also wasn't so sure about the uterus fundus because she couldn't feel it well but certainly there were contractions. From the history we were prepared for the worst and probably a caesarean section. A quick but thorough routine ultrasound was done and there was no pregnancy even though the contractions were real. The woman ofcourse cursed and blamed it on witchcraft by her enemies who had taken her baby from the womb in the last minute to delivery. But there was no witchcraft, the diagnosis was PSEUDOCYESIS in a woman so desperate for a baby. Pregnancy test was negative.   Back to my first patient, I started treatment for her and she accepted her condition albeit half heartedly. I prescribed to her antidepressants for the psychological problem and bromocriptine to arrest the milk production. She has been faithful in her monthly follow-ups for the last 6 months and slowly we have been successful in 'reversing' the pregnancy. The abdomen has markedly decreased in size, her face is no longer puffy, her monthly periods are back and the milk production has stopped . The baby 'kicks' have also disappeared.  I hope from this post on PSEUDOCYESIS we get to acknowledge the power of the mind.  If the mind is so powerful as to simulate a false pregnancy then imagine what more it can do. This reminds me of a quote that says;  'The greatest force is derived from the power of thought. The finer the element, the more powerful it is. The silent power of thought influences people even at a distance, because mind is one as well as many. The universe is a cobweb; minds are spiders. - Swami Vivekananda' I hope you have a lovely week ahead and get to utilize the power of the mind to achieve great things in life. 

ABORTIONS AMONG MARRIED WOMEN

ABORTIONS AMONG MARRIED WOMEN This past week, I witnessed a rising number of abortions among married women. I really couldn't understand what would make a married woman want to terminate a child born within the family unit. If it were a teenager or a single woman, or even a widow, I would understand.     Kenyan statistics indicate that there are about 310,000 abortions every year in Kenya. 21,000 women are admitted each year due to abortion related complications from having unsafe abortions – usually done in backstreet clinics. 2,600 of these eventually die. Of the women admitted, 12% were older than 34, 40% were between 25 and 34 while 16% were teenagers.  Clearly the more mature women above age 25 take the lead.  I usually break pregnancy news with a smile and a congratulatory note but this week I was faced with rude answers and tears among some of the women. Many cried uncontrollably and I had to probe further and ask what had triggered the sadness. They were after all married and with other children. They all complained of the rising cost of living and lack of happiness in the family. Some stated that their husbands were less concerned about taking care of the children and that the women had to hustle singlehandedly to raise the children.  A few begged for abortions but I was very frank with them that it's a crime in the Kenyan law and a big sin in the eyes of the Lord. I did counsel them and told them they should take it as a blessing and reminded them that there are many women who are desperate to have children. One lady told me that God should have taken what was in her womb and given it to a more deserving desperate woman.   We have had cases of women who come in with ruptured uteruses or sepsis only for us to find big rough sticks, metal rods, wooden objects etc that have gone through the uterus into the abdominal cavity. All these are usually among married women in their 30s and 40s. The teenagers are usually surprisingly less 'radical' in their methods of terminating pregnancies. I must say that older women have guts.  Most of the time when I get married women coming in with pre-term labour or abnormal bleeding in pregnancy, i'm usually very tough and demand to know what they used to illegally trigger labour. It's mostly strong concoctions taken or objects inserted into the uterus.  So what is causing so many abortions in family units? Are our husbands too busy at work to remember the family, is it alcohol and substance abuse, is it because of extramarital affairs and they end up neglecting their wives and children?  Or are women increasingly wanting an emotional and psychological readiness before carrying on with a pregnancy?   Those from the urban areas say it is more of a lifestyle choice than anything else because they would, for example, rather pursue a career than have a child. Increased westernization of the country has made traditionally large families to be frowned upon by many modern women in general. The average child per woman in Kenya in the 70s was eight, while today, the figure is just under three. How do we prevent this vice in marriage?  In my opinion, every woman after delivery should be advised on the different contraceptives before discharge from the maternity. The husbands should actively participate in the choice and use of contraceptives. Women nearing 40s can be advised on more permanent methods of family planning like tubal-ligation (Can our men agree to have vasectomies????). Men should be more dedicated in caring for their families. A law should be passed to arrest and charge any woman who attempted abortion; but this would mean that such women would be scared to come to hospitals and would die at home from life threatening complications. It's a very controversial topic. It's something that needs to be discussed and analyzed more deeply.  I will end my post today with a reminder of the Kenyan laws on abortion.  Abortion Laws in Kenya Article 26 in the new constitution was the bone of contention between the pro-life and pro-choice groups in the build up to the referendum. Article 26 of the Constitution contains 4 clauses on the rights to life which state that: 1). Every person has the right to life; 2). The life of a person begins at conception; 3). A person shall not be deprived of life intentionally, except to the extent authorized by this constitution or other written law; 4). Abortion is not permitted unless, in the opinion of a trained health professional, there is a need for emergency treatment, or the life or health of the mother is in danger, or if permitted by any other written law Have a happy valentines week!!!

D.V.T - THE SILENT KILLER

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This week I assigned myself the task to make a presentation about Deep Venous Thrombosis (DVT) to my colleagues in Chaaria. Its a silent killer that kills in seconds. It reminds me of the death of a popular TV personality who was found dead on her bathroom floor sometime in September. Rumors went round about the possibility of poisoning or bathroom accident because she was as fit as a fiddle but autopsy made a conclusion that she had succumbed to embolism from a DVT.

DVT is the formation of a clot in the deep veins of the limbs especially in the legs. If the clot dislodges( what we call embolism) and goes to the lungs, it causes death in seconds. I have atleast two DVT patients in the wards every month. A few succumb to embolism because they present to the hospital with breathlessness when it is too late. I have had to force some of the patients to be admitted in the hospital despite resistance. I confront them and tell them point blank that I do not want to be responsible for their deaths. It's one condition of which I put my foot down and refuse discharge against medical advice.

So how does it present? How do you know that you could be suffering from DVT? It classically starts as swelling of one leg which could be painful especially at the calf. The leg might get warm and reddened with time. Superficial veins sometimes get visible and in the extreme cases, the limb might get gangrenous or start turning blue. What are the risk factors for DVT? These are generally categorized into factors that cause Stasis of blood in the limbs, increased clotting of blood in the body and injury to major blood vessels. These include being immobile for long hours or days(especially in bedridden patients or long distance travellers), cancers which predipose to hypercoagulation of blood, trauma or fractures of limbs, recent abdomino-pelvic surgeries (e.g hysterectomy, prostatectomy, caesarean sections etc), recent bone surgeries(orthopedic surgeries), use of estrogen containing contraceptive pills, cannulation of major blood vessels of the body especially in dialysis patients,patients with diseases like nephrotic syndrome, pregnancy e.t.c. The list is endless.

Diagnosis requires color duplex ultrasound of the affected limb. This can be combined with other more complex investigations. Treatment requires compulsory hospitalization for anticoagulation and strict follow up in the months that follow. ( I will not bore you with the specific treatment modalities). So if you develop swelling of one leg no matter how innocent it looks, run to the hospital before death runs to you. It's not proper to ignore. We should also avoid sitting or lying down for long hours. This targets everybody including those who sit in offices for long hours, long distance travellers or frequent air-travellers. Those who are in hospital and having undergone surgeries should learn to ambulate early and walk around. How many times have we heard of stable patients collapsing on discharge or collapsing in the toilet just before discharge? (Why is the toilet the most common place for death in DVT patients? Food for thought!!!!). Or how many healthy people have we heard found dead after a perfectly normal daily activity.

Let's be careful. Let's spread the information and learn to take any swelling of one limb seriously. Let us also get active. That simple standing from your chair and going to the dispenser in the office could save you from death. The frequent air travellers should learn to walk to and fro the aeroplane isles at-least 3 times in the flight (DVT is also called the 'pilots disease'). I hope that this week's post will help someone out there. Have a great start to February!!!! BEWARE!!!!! Let's be alert.

CANCER 2

Following the previous week's post on cancers, I did get many responses, comments, suggestions, cancer stories that made me cry  e.t.c. Of note was a message from 'Brian'(not his real name), one of my cancer patients aged 21. He messaged to ask why I had not included his story in the post. I had actually written about him but deleted the paragraph the last minute because I needed his consent first. I met Brian in April-May 2014. By that time I was working at Meru Hospital and would only come to Chaaria during my free time. He came for his histopathology report for stony hard masses that had developed in his abdomen. The report read  'Desmoplastic Small Round Cell Tumor'. What was that? I had never heard of such a name. There is a chance that it was somewhere underlined or highlighted in my pathology textbooks and notebooks during medical school but I couldn't remember what it was. Are these not things we read just to pass exams and quickly forget about them because they are rare? Was it malignant or benign? What was it's nature? I dashed to my boss's office where we have a mini-library. I couldn't get it in the first book I checked and almost immediately my boss and our most senior surgeon Dr. Pietro walked in and I informed them of my dilemma. They informed me that it's a rare type of soft tissue sarcoma that mostly affects males at the adolescent age or early 20s. It mostly presents as abdominal masses of no known origin. The sarcoma responds very well to chemotherapy. Armed with this information, I dashed back to my office and explained what I had just learned to him. He had not come with his parents so i counseled him the best I could like a younger brother. Brian was surprised but he had the motivation to seek specialist help without delay. I wrote his referral letter and took down his number because I wanted to follow up. He was very brave and I could see determination on his face  to conquer this illness. I naturally expected review in KNH after a few months but because of his drive and enthusiasm, Brian was able to get booked for chemotherapy without delay. We keep in touch at least once a week and he is well, almost done with Chemotherapy. He is responding very well to treatment but he tells me that sometimes he gets very weak after Chemo sessions. The journey he says, has not been easy. There are times he messages me that his white blood cells get down and he has to boost them with Neupogen, there are times his Chemo drugs run out of stock in KNH and he has to wait longer for his sessions, during the KNH doctor's strike he had problems getting doctors to administer his chemo,he has lost weight etc. Brian gives me the motivation to face life positively. He is doing very well and responding well to Chemo.  He tells me that he is the first person in his family to have cancer but he has taken it positively. He tells that the KNH oncology clinic is always flooded with patients and he only gets seen in the afternoon despite coming in very early due to the long queues.  Brian's is a success story,he says his life has not changed. He refused to let cancer change his life.  I'm praying hard he becomes cancer-free and becomes a motivation to other cancer patients.  I hope we all learn from him. I'm so glad our paths crossed and he is truly a source of inspiration.


   The next person who messaged me about her story validated something that a surgeon had asked me in theatre one day. We were doing a thyroid lumpectomy and the  surgeon asked me if we had done cytology or needle-biopsy of the thyroid lump. I had not thought about it because we were going to send the removed lump for histopathology anyway and thyroid cancer is extremely rare in our setting. I have never seen any case of thyroid cancer since i graduated. All our histopathology reports gladly come back negative for malignancy.  The incidence in Africa is  1 case out of 200,000 population per year. This friend messaged me that she was touched after reading my post. She had lost a close relation to Thyroid Cancer in the age-gap of early 30s last year. It was a thyroid lump that was never investigated properly and in the end the lady lost the battle to metastatic thyroid cancer. It's a mistake that all of us in the society and us doctors make by presuming that any thyroid swelling or Goitre is benign. The message made me think deeply and conclude that all thyroid swelling must be biopsied before surgery and still sent for histopathology after surgery . The cancer might be very rare in Africa but that one life lost is a lost generation, a lost parent, child, sibling, friend e.t.c.  We should not take chances with thyroid swellings no matter how rare the cancer is.


 This week, we had a class by Fr. Gaido about Esophageal cancers. He mentioned to us that it was so common among men from the North to the extent that any male patient from the North presenting with painful or difficulty in swallowing is almost always esophageal cancer . I have had arguments with some of them when I recommend OGD, they insist it's not necessary only for most of them to turn out to be cancer.  We discussed why it was a common disease in that area of the country and especially on men. Is it because of taking very hot burning tea? Does the resulting corrosive injury lead to cancer? Women only get to take the tea after the men have had their share so their tea is usually cold by then. Is this why the cancer hardly occurs among women of the same region? Think about it and tell me. 'Tafakari hayo.'  I'm considering doing a research on this.  Similarly, Liver Cancers are so common among Kambas especially those from drier parts of the region. Is it because of aflatoxins from poorly stored maize? Have a good week ahead. I pray that the blog-posts impact positively on each reader's life. 

THE CANCER MENACE IN THE 20s-30s AGE-GROUP

  It's Monday the 19th January 2015 at 5.30p.m and I'm lazing on my couch trying to review something. My mum calls me and tells me that she has not seen my blog-post for the week. I told her that I didn't feel like writing because my last two posts did not get much reads. She reminded me that that's the life of a writer, there are high and low seasons. I got motivated, dropped the book I was reading and started writing. I had so much to share, I could feel it boiling up in me. 

  Last week was a very tiring week for me. The magnitude of the diseases I saw was too heavy for me to bear. This is because it mostly involved my age-mates. Let me brand the week's experiences 'cancers affecting my agemates' We diagnosed two breast cancers in    girls old enough to be my age-mates if not younger . One of the girls allowed me to share her story. The little girl in her early 20s came in with complaints of a breast lump.  On the first half of the history, I automatically presumed it's the harmless Fibroadenoma mostly encountered in late teens and early twenties.  I thought so because of her age.  Examination of the breast and further analysis of her previous medical notes made me conclude the worst. It was breast cancer !!! Yes, at that young age. We went ahead and recommended a mastectomy which was done later in the week . I was almost in tears. Here was girl, younger than me and having to bear such sad news. Infact, she is the age of my younger sister. I couldn't imagine my sister going through that, she is too young; she is a baby. Despite being a medic and having the knowledge , I have always intentionally  presumed that breast-cancer is a disease of the 40s and above . But here was a girl, barely past her teenage-hood and diagnosed with it. I don't remember the last time I did a self breast examination, are we too ignorant and presumptive? We diagnosed her cancer at stage 3. Is there a chance that it would have been diagnosed much earlier? How often do women from age 13 examine themselves or report any minor anomaly? A Breast cancer relapse in a patient in her 30s who had fast become a friend topped up my sorrows for the week. We had successfully done her mastectomy two months back but she couldn't access chemotherapy/radiotherapy because of the inadequacy of such facilities to the poor patients in the country. Sometimes, you cannot avoid taking patient issues too personally. This reminds me of cases of three women, all at age 30 who came to the hospital at different times with  complaints of heavy persistent menstrual periods. We all thought it was Dysfunctional Uterine Bleeding(D.U.B), fibroids or the side effect of contraceptives. Ultrasounds confirmed the worst. They all had 'cauliflower' masses arising from the cervix. On vaginal examination, they had fungating,friable and bleeding cervical masses. (We should have done the examination before the ultra-sounds but African women are hesitant to have vaginal examinations during menstrual periods). They had Cancer of the Cervix. They were shell shocked. They had come for simple medication to stop the 'periods,' only for them to learn that it was not periods.  We did a biopsy and histopathology confirmed all the three cases. They had come to pick the results last week. I had to endure the heavy task of breaking the news and giving advise on what to do next. One of the lady stared at me in shock and asked me to slowly repeat what I had been saying because she had switched off completely in panic and fear. To her, it was like a death sentence. All three are exactly 2 years older than me, with dreams and ambitions, but cancer had come to interfere with their good life. I could feel their pain. None of them had the history of cancer in their families, they had started the history!  When did you last have a pap-smear done? It could happen to anyone. It knows no age group and it doesn't matter that you don't have a family history. 


 There was pancreatic cancer diagnosed on a 29 year old. We all presumed it was distal stomach cancer after a series of investigations and had him set for a partial gastrectomy (removal of half the stomach). In theatre we sadly learned that it was  pancreatic cancer. An inoperable cancer. It's what claimed Steve Jobs' life ; the founder of Apple Inc. It was very sad! Wasn't cancer a disease of the west?? I have learned to be careful. I have stopped taking things for granted. I have stopped presuming that cancer is a disease of the old timers. Each time I'm tempted to skip eating fruits and vegetables, I remember my two advanced colon cancer patients who died at age 35 and 38 respectively here in Chaaria. Each time any of my family member presents with acid regurgitation I treat them promptly to avoid barrett metaplasia and consequently cancer of the esophagus. Each time a patient comes in with a persistent lymph-node enlargement I quickly advise on a lymph-node biopsy because hey, I have already seen more than 5 lymphomas this year. Each time I hear anyone complain of bloody urine, I quickly dash to do an ultrasound; haven't we diagnosed bladder cancer on girls in their twenties? I associated almost everything with cancer last week. It got to my head so much, I could have easily misdiagnosed simple TB for Lung-cancer. I didn't want to presume anything. It's good for all of us to be on the look-out. A small ailment could end up being a horrific experience if not followed up early. Most cancers are also preventable by making simple lifestyle modifications.    

 There you have it. I hope that we will all be on the alert and stop taking things for granted.  I pray that all cancer patients receive the care they deserve and get on with their lives . I hope that a time is coming when cancers will be detected timely and completely cured. I mostly pray a time is coming when all cancers will be preventable.  P.S: Cottolengo Mission Hospital should be made a cancer diagnostic centre. We diagnose at least 15-20 cancer patients every week. The top on the list are the many esophageal and stomach cancers, the many liver cancers mostly from Tseikuru, prostate cancers , colon cancer once in a while, nasopharyngeal tumors, occasional brain tumors, the many lymphomas,cancers of the head of pancreas has become the first differential diagnosis in patients with obstructive jaundice. The list is endless.

AFRICAN TRADITIONAL MEDICINE

It's the 1st of January 2015 at around 8.00a.m and I'm lazing on my bed in Machakos. My mum walks in to wake me up and immediately after wishing her a happy new year I ask her if there are any PPI's (antacids) in the house. I was bloated, having serious GERD, hyperacidity and was convinced that I must have caught H-pylori. I happened to be sharing my room with my grandmother Mwaitu who had come to visit us. Immediately grandma heard me ask about antacids she told me that I was definitely having KAVASO and she would 'lift' it for me. KAVASO is  a Kamba word for epigastric pain and hyperacidity  believed to be caused by retraction of the sternum and subcostal region mostly associated with stress. It can be lifted with oily warm hands or using a cup heated up to create a vacuum. I don't really connect the pathophysiology behind KAVASO and hyperacidity so I naturally refused to have it 'lifted.' After coaxing and explanation, I agreed to have the 'procedure' done just to please grandma.  One has to be Nill Per Oral (N.P.O) ; i was all set because I had just woken up. She rubbed glycerine on her palms and the painful exercise started. She dug her fingers deep behind my subcostal region and sternum and literally lifted my rib cage. It was very painful (there was no anaethesia used) and I was screaming. She told me that I was a terrible patient and had to learn to endure pain. She went ahead and made 'intra-op finding' of my KAVASO being 'swollen' and that I would need 'post-op' care in form of bitter herbs to be taken once daily for 3 days. I decided to faithfully take the concotion out of curiosity.  I still couldn't make any connection between the rib-cage and hyperacidity. The procedure ended well and we went to have breakfast with the family. There was alot of feasting during the day and the days that followed,   spicy food, nyama choma, fizzy drinks and generally unhealthy eating. I did not get any hyperacidity or epigastric pain despite the sinful feeding. Did grandma's treatment work? What's the medical connection and pathophysiology of KAVASO as an illness ? I don't know!! I probably need to do a research on this, formulate a hypothesis and see if there's any explanation; who knows, it could be a new medical discovery.   

 The previous day, a heavily  pregnant neighbour came in and told us that she had breech presentation(legs first) at 30weeks discovered on examination and on ultrasound. I did Leopold's Monouver on her and confirmed the diagnosis. I reassured her that it would be well  but  advised her  that if the baby remained in such a position at 38 weeks then she should opt for an elective caesarean section.  My grandma jumped in and told us that the baby could be turned traditionally to cephalic presentation( head down). I needed to know more about it and she told me that she had done the procedure to several women successfully over the last 40 years . My own sister was a breech and was turned to cephalic presentation at 40weeks just 4 days before she was delivered normally and without any complications . This correlates perfectly with an obstetrics manouver called EXTERNAL CEPHALIC VERSION. After explaining the traditional procedure to me, I realized that it was exactly as explained in Obstetric text books.  It is known and accepted in modern medicine but not widely practised now due to the complications that may occur; some parts of Europe and America still practise it but under strict ultrasound monitoring. We got talking more and I realized that my own style of doing obstetrics examination was almost similar as my grandma's. She told me that she had even done INTERNAL CEPHALIC VERSIONS (through the vagina) successfully for transverse  and oblique presentations that had come in labour mostly during the colonial era . There were stories of successful 'incubations' for pre-term and low birth weight babies using banana leaves and warm ash under strict controlled temperatures those many years back. It was a very interesting talk and i agree that probably the only thing our wise old women didn't know was how to perform caesarean sections ( I should probably invite grandma to theatre one day). We concluded that indeed the external cephalic version is a manoouver that could be done but we expounded on the possible complications, how they present and what to do in the event that they occur.    


  When I had mumps in childhood at 9 years, I was successfully managed by my grandma. We had an adventurous way of managing it that was well known by the kids in the neighbourhood.   She took me to a river very early in the morning at around 6.00a.m . Calabash derived ornaments were hang on my ears and we sang and danced a known 'mumps song' in  Kikamba while facing a tree called KIVUTI. 'Kivuti mbunye ngumbu, na tata ndae ngumbu, na mwaitu ndae ngumbu' (Kivuti remove my mumps, father did not have mumps, mother did not have mumps). We then hang the calabash ornaments on the tree branches and I was told to run home straight without looking back or talking to anyone on the way . The mumps would apparently be 'transferred' to the tree. In just one day I was totally mumps-free and back to school. As a medical doctor now, I try to give a medical meaning to this traditional treatment and I realize that it's probably all in the mind. Mumps being a viral illness is self-limiting so it was going to heal without treatment anyway. I only give paracetamol and recommend oral rehydration to kids who present in my office with mumps and reassure them that it would heal on it's own. I however give special consideration to male children just incase they get orchitis (testicles inflammation). My own children will undergo both traditional and modern treatment of mumps to get a feel of their culture and customs.

 I can go on and on about experiences in my childhood. For instance Mwaitu was my 'dentist' as I grew up and my teeth are perfectly aligned (a beauty model would be jealous). She would fill my cavities with raw pawpaw pulp and the 'fillings' have remained intact for over two decades. A septic leg wound resistant to antiobiotics was successfully treated using fresh Aloe-Vera juice and it completely healed with no scar.    There you have it, should Traditional African Medicine be mixed with modern medical practices? You tell me and feel free to share your thoughts and experiences. My drive to study medicine was highly influenced by my two maternal grandmothers;  probably it's a gift that has been passed down but in form of modern medicine.