Day 5: Outreach Day - Guest Blogger: Dr. James

[James Aw, MD, is the Chief Medical Officer at Medcan with a special interest in adult medicine and global health]

 Here I am with Nurse Lydia and Nurse Hagai at the end of the outreach. The day started with lots of people eager to be seen at our outreach in the Meru district.

Here I am with Nurse Lydia and Nurse Hagai at the end of the outreach. The day started with lots of people eager to be seen at our outreach in the Meru district.

It was great to be back at Lewa and reunite with the Kenyan clinical team.  Today – the team went on a community outreach and were paired with up with clinical nurses seeing patients in the Meru district.  The Kenyan clinical team also acted as translators for Swahili and the other local tribal dialects.

The physicians (Sue, Michael, me) and optometrist (Sidiqa) focused on medical consults while the rest of the team were busy with training, community health surveys and logistics (including crowd control).

I saw a nice variety of cases today with my Kenyan clinic nurse partner Hagai at the outreach.  A few of them stood out.

 The skies were clear and the lines long on this outreach day. While local residents and people who had travelled hours to see us waited at two separate entrances, I was inside treating patients who had been triaged by the local and Naweza nurses

The skies were clear and the lines long on this outreach day. While local residents and people who had travelled hours to see us waited at two separate entrances, I was inside treating patients who had been triaged by the local and Naweza nurses

 Stacy Francis and the Lewa nurses (at bottom left) upon arrival at the outreach location. Patients wait to be introduced to this outreach's clinicians

Stacy Francis and the Lewa nurses (at bottom left) upon arrival at the outreach location. Patients wait to be introduced to this outreach's clinicians

 Registered Nurse Vanessa is part of the triage process of patients before they reach my door

Registered Nurse Vanessa is part of the triage process of patients before they reach my door

Case 1: Man with type 1 diabetes

The first case of the day was actually at Lewa Clinic before the community outreach began.  He was a 21-year-old known Type 1 diabetic who had stopped taking his insulin for a few days and was vomiting and dehydrated (he ran out of his insulin). 

His blood sugars were quite elevated and he was dehydrated.  He was vomiting, dizzy, dehydrated and feeling terrible. The team tried to set up some IV lines – but his veins were collapsed and it was very difficult.  After multiple attempts, we were able to secure a couple of IV lines and pushed fluids to get him rehydrated, and normalize his sugars.  We then could reintroduce the insulin while monitoring his potassium levels. 

This case was particularly timely because I had just days before given a couple of talks on high sugar emergencies (hyperglycemia and diabetic ketoacidosis) and diabetes.  However – it also reminded me of the challenges of living with diabetes in remote areas of Kenya. 

Some locals will dig holes in the ground to store their insulin – but there is no guaranteed temperature control, which can affect the efficacy of the insulin. 
— James Aw, M.D. on the challenges of living with diabetes in remote areas
 Wooden panels and a small chimney made of corrugated steel are typical characteristics of the cooking areas for the residents of Lewa - the set up can lead to respiratory and vision problems, of which we saw a lot among our patients during the outreach

Wooden panels and a small chimney made of corrugated steel are typical characteristics of the cooking areas for the residents of Lewa - the set up can lead to respiratory and vision problems, of which we saw a lot among our patients during the outreach

Insulin should be refrigerated – but this is not possible in remote areas. Some locals will dig holes in the ground to store their insulin – but there is no guaranteed temperature control, which can affect the efficacy of the insulin. If a Type 1 diabetic can’t get regular access to insulin – then they will keep falling into these preventable diabetes emergencies.  Also – if patients have poor control of their diabetes then they will have an increased probability of death or end-stage complications.  The supply chain of insulin and storage of insulin in remote communities remains a challenge in Kenya.

(The following video is a quick tour of a local resident's cooking area, and may offer a better understanding of the living conditions of some of my patients.)

Rosaline, Infection Control and Facilities Manager at Lewa, gives Tania Haas, Documenter and Engagement Survey Lead, a quick tour of a local resident's cooking area. The ash and smoke from the open fire leads to widespread respiratory and vision problems among the community.

 

Case 2: 20-year-old woman with joint pain and muscle wasting 

Another interesting case in the community outreach was a young woman in her 20s who had been suffering for years with joint pains, rigidity, weight loss, fatigue and muscle wasting. She told Hagai and me that she was unable to complete school because of her symptoms. 

 Young adult woman visited me with complaints of chronic joint pain and weight loss

Young adult woman visited me with complaints of chronic joint pain and weight loss

When examining her – she had swollen inflamed knee joints, muscle atrophy and rigidity in her upper limb movements.  The chronic inflammation was wearing her down.  It looked like Juvenile Rheumatoid Arthritis (JRA).  I brought in the other clinic nurses and my colleague Dr. Michael to do a case review. 

She reminded us of another case at Lewa Clinic of a young adult who had end stage Juvenile Rheumatoid Arthritis who we assessed on previous trips.  Unfortunately – that patient had more advanced disease and wasn’t a candidate for immuno-suppressive treatment (i.e. methotrexate).

  The hope was that early detection of JRA might help this young woman. 

The hope was that early detection of JRA might help this young woman. 

We decided to refer her to a rheumatologist in Nairobi to assess her candidacy for specialty drugs to prevent end-stage complications.  We decided to bring her to the Lewa Clinic and get some baseline blood work on her and start her on some prednisone with follow up to treat her symptoms. 

This woman reminded me about the importance of early detection, case management and education of the Kenyan clinical team.  Case reviews on past cases helped us to deal with this particular patient.

Case 3: An elder with a massive foot lesion

An 80-year-old man showed up to the clinic limping with a cane.  He had a massive growth on the sole of his foot that was bleeding.  It didn’t look like an infectious lesion and we ruled out diabetes with a random blood sugar.  He looked cachetic (cachectic [kuh-kek-see-uh] means general ill health with emaciation) and weak – but had managed to live until 80.  He was a resilient man but the foot mass was impacting his quality of life. 

On examination, his foot lesion was a massive growth that looked like a form of foot cancer. (It was likely benign because he was living into his advanced age. That being said, it would have been much easier to treat if it had been caught much earlier in the disease process.)  We decided to refer him to a local hospital to see a surgeon who could hopefully sample the lesion (i.e. make a diagnosis) and debulk the foot mass so that it would improve his quality of life.  We dressed the wound and arranged the referrals.

Case 4: Young woman with bilateral swollen lower legs

Another case that was interesting was a young women who presented with bilateral swollen lower legs.  On examination – the swelling appeared to be of the lymphedema type.  One of the causes of lymphedema in tropical medicine is a condition called filariasis, which is treatable.  The large swelling of the legs from the infection transmitted from a mosquito bite is also known as “elephant-iasm” because the lower legs become so big. 

 This case of bilateral swollen lower legs had become so severe that the patient was having trouble walking and was avoiding social interaction

This case of bilateral swollen lower legs had become so severe that the patient was having trouble walking and was avoiding social interaction

After consulting with the local nurses from the region, however, our position changed. The Kenyan nurses stated that filariasis is more prevalent in coastal Kenya.  With this information, we decided to send her to a local hospital (Isiolo Hospital, which we visited on Day 2) for more advanced testing to determine the diagnosis (either by looking at a sample under the microscope and/or a blood test).  If she is found to have the condition, then it can be treated with medication (i.e. DES), which would drastically improve her quality of life.  It was an interesting case of tropical medicine that required team work on determining the diagnosis and securing the treatment.

Outreach Feb 2018: another day fascinating day of rural medicine and collaboration

We saw several more cases at the outreach and the lines were very long.  The types of cases that I saw were more focused on general adult medicine, and included a wide range of conditions like cardiovascular disease, diabetes, thyroid disorders, skin tumours, stomach disorders, abdominal pain, prostate diseases and lots of musculoskeletal complaints (osteoarthritis and aches and pains from hard work as farmers and labourers).

It was another fascinating day of rural medicine and collaboration with our Kenyan colleagues. 

Video from Day 3 when Nurse Hagai and Dr. James discuss the highlights of the Continuing Medical Education presentations and the subsequent group learning at the Lewa Clinic