Cervical Cancer

Assuming that we all remembered to include; “taking my healthcare more seriously” in our 2019 resolutions or plans, it is my duty then to impart you with the knowledge that you will need to help you stay healthy.

According to the 2019 WELLNESS AWARENESS calendar, January is the world cervical cancer awareness month. Now cervical cancer is one of the most treatable cancers but sadly our people continue dying from its complications. It is the second leading cause of cancer deaths among women after breast cancer according to the Kenya Network of Cancer Organizations. This is mainly because of the fact that they present to the hospital when it is already in advanced stages, when the doctor cannot do much except just make them comfortable while they await death.
This doesn’t have to be case. We can decide to do better as patients, as a society.

Here is what we need to know about cervical cancer;

The cervix, also known as the uterine cervix is the lower part of the uterus, normally cylindrical in shape, and about one inch long. This is the part that is normally affected by the cancer, before the cancer cells move to the other parts of the body in a process called metastasis.
Unlike other cancers whose causes are still unknown, cervical cancer has almost always been associated with the infection with human papilloma virus (HPV) especially sub types 16 and 18.

HPV IS SEXUALLY TRANSMITTED.

It appears to be common in women who have multiple sexual partners, women who smoke, women with a low immunity (HIV positive), and also women who start sexual relations at a younger age, and those with promiscuous male partners.

After infection with the human papilloma virus, it usually takes about ten to twenty years before the cancer develops. This is good news because it means that if a woman presents at this time to the hospital, then something can be done before the actual cancer develops.
Prevention of cervical cancer;

Well we obviously have to reduce the risk factors; don’t smoke or stop if you already started, reduce the number of sexual partners to one (it is possible right?), dump promiscuous sex partners.

VACCINATION AND SCREENING
If we have any plans as a country to eliminate cervical cancer like the way most countries in the West have, then we need to embrace vaccination and screening as the strategies. If the government is very serious about the delivery of Universal Health Care, then we can do what other countries have done; develop a system of vaccinating our young girls against HPV.
The government could also incorporate screening services and a system to refer patients who have positive pap smears in services provided in government facilities.

VACCINATION:
Cervarix and Gerdasil are vaccines that are available locally and are used against the human papilloma virus which is the causative agent of cervical cancer.
Girls from the age of nine to thirteen are eligible for these vaccines.
Cervarix
Is active against HPV 16 and 18
It is administered in three doses at 0, 6 and 12 months intervals
Can be given to girls aged between eleven and twelve

Gardasil
Active against HPV 6, 16 and 18
Administered in three injections six months apart
Can be given to girls aged between nine to thirteen.

SCREENING
The most common screening method is the PAP SMEARS.

PAP SMEARS
When did you last have your pap smear?
Have you ever had a pap smear?
Do you know what a pap smear is?
Papanicolaou smear or just pap smear is a screening method used to identify pre cancerous cells in women.
Women below 21 years of age do not need screening.
Women aged between 21-29 years will require pap smears every three years.
Women aged between 30-65b years of age, who have had negative pap smears will requitre to go for pap smears every five years.
Women who are HIV negative though require yearly pap smears or as directed by their doctors.

If for some reason you had your uterus removed; complete hysterectomy, then you don’t need to go for pap smears at all.

 

Merry Christmas

HAPPINESS EVERYWHERE….
It is that time of the year when we celebrate the birth of Jesus and the festive mood is present everywhere! Television and radio stations are playing Christmas carols, supermarkets and shopping malls are all decorated in bright colored balloons and glittery lights. There are Christmas trees everywhere, decorated with bright lights that keep winking at us as we walk around, reminding us that it is Christmas.
As everyone else travels to the village to celebrate with their relatives, he (let us call him Mark), Mark lies in the hospital bed unaware and uncaring about what is going on beyond his field of vision. It is two or three months since he was allowed to go home. And for these three months, he has been lying in his bed, trapped in his own body, unable to move any part of his body from his waist downwards.

The doctors found tuberculosis in his spine and put him on medication. But he is yet to get better, and it may be too early to hope for anything because he is supposed to take them for twelve months; yes, one whole year of his life, dedicated to swallowing tablets. For three months he has lain in that hospital bed and waited. Initially, the problem was the hospital bill. But his hospital bill was waived and his family didn’t have to pay for anything. Still, no one came to get him. And so he has been lying on that bed day in, day out. Every time he wakes up and opens his eyes, the first thing he sees is the roof over head. His eyes land on the same spot overhead and he can see it clearly even in the eye of his mind with both of his eyes closed.

Each day is the same in the hospital they are served the same watery tea and three pieces of poor quality bread at seven in the morning. Then the nurses pass around from bed to bed making their beds. At his bed, they pause, change his diapers first, then change his beddings. They also remember to turn him then. If he is lucky, he receives a bad bath once in a while and a change of clothes. Then the doctors pass round and when they reach at his bed, greet him. There is really nothing more they can do. He is already on anti- TBs. They remind the nurses to turn him every two hours and they remind him to feed well. Recently, they add anti-depressants to his treatment. He is depressed. It shows in his face, in his refusal to talk and his poor appetite. And they will call the plastic surgeon to come and look at his bed sores. He has developed large ugly bed sores on virtually every pressure point on his body; over the sacrum, the hips, the heels, the elbows, the cranium; everywhere a pressure ulcer can develop. Sad right?

And today, amongst all these cheer and happiness, I can’t just push his emaciated body off my mind. He keeps popping up and I can’t stop imagining what he was before he became para-plegic; he definitely was a man with goals and dreams of his own. Dreams he has been forced to forget about because well, he is in the hospital and he doesn’t know how to get out. Because what he needs is not just money but someone, people; friends and family. Maybe they will give him a reason to fight, to start feeding and maybe to turn him as frequently as he may need to be turned.

Like Mark, so many patients find themselves trapped in almost ‘useless’ bodies. Either as a result of brain injury from one cause or another, or even spinal cord injuries either due to disease or accidents. You can only pray to never find yourself in that situation. Meanwhile, how about we think about how these people’s lives can be made better? As things stand, we will never have enough nurses to turn these patients every two hours, at least not in the next ten years. But maybe we can buy them a ripple mattress. A ripple mattress is actually a device that can be used to prevent bed sores in patients who are bed ridden. The ripple mattress is sold with an external pump that alternates the pressures in the different compartments of the mattress, allowing for pressure to alternate on the skin.

If you are looking to gift anyone this Christmas season, you can gift a public hospital near you with a ripple mattress…..there could be someone there who could use one.

Ripple Mattress

Merry Christmas!!!

Nyumba Ya Wazee (Part One)

Old patients who have suffered debilitating strokes are the hardest to take care of. These ones need round the clock nursing. After suffering a stroke, most old people never recover fully. They are forced to live with the residual effects of the stroke. These people, will, most of them for the rest of their lives, need help in carrying out virtually every activity of daily living. They will need help with getting to bed, turning, feeding, urinating, pooping, showering, dressing, brushing their teeth et cetera. Most of these people will also need at least two weekly visit to a physiotherapist and regular check-ups by a doctor.

Now most of us have terribly failed our ailing parents and grand-parents. Because we are perpetually busy looking for money to buy food, property, pay hospital bills and repay the Chinese people their loans, we rarely are able to be there to provide this kind of care to them. A few of us try. We employ house-helps to stay with them and do all things on our behalf. But the house-helps soon get overwhelmed. And the fact that old people are stubborn doesn’t help make matters any better. So our old relatives end up staying alone. They sleep on one side for enough days till we are able to squeeze a few minutes in our busy routines to turn them. The result is the big ugly bed sores that almost each one of them has. Some skip meals and their drugs, and physiotherapy.

Photo courtesy/ nation.co.ke

The only thing that we try to do is take them to the hospital when their clinic days are due. But no one stays around to turn them two hourly, to change their beddings, to help them wash up or even to administer their drugs. But when their clinic days are due, we show up in our cars, wash them up and bundle them into the back seats. We march to their clinics and demand to see the doctors, make a lot of noise about delays, demand for lots of tests, get the medication and drop them off in their miserable homes.

Some of us even walk to the hospital and demand that our parents be hospitalized in the best possible sections of the wards. Because we can’t take care of them at home. We want nurses and doctors to keep our old in the hospital and do everything in the hospital. Maybe this works, in private hospitals. Public hospitals are however no place to dump our old. Those places are teeming with humanity and disease causing organisms thrive in the hospital air.

That is why we need to have this conversation about homes for the old and sickly. Instead of pretending to be nice African children, we need to embrace anything that would make our lives easier. How about we admit these old people in professional homes where there are people to take care of them around the clock? How about we admit them there and never worry about them missing their drugs, or overdosing, under dosing or worse still, being found dead alone? We could let them go there then try and visit them as often as is possible.

Homes for the old might not be popular in these sides of the world but we can make them friendly. Have qualified people to see to the needs of these old people. Design nice games for them to play. Arrange road trips for them et cetera.

Health Is Now Devolved

Photo source: The Sun Nigeria.

A twenty-year old walks to the County referral hospital with the dignity of a married woman, tummy protruding before her, she is walking with her legs slightly apart, thanks to her protruding belly. She is in the company of three women; her mother in law, her own sister and an elderly neighbor. Every twenty or so minutes, she pauses, puts her hands on her waist and takes long purifying breaths as a strong contraction starts at the fundus of her uterus and radiates down, causing indescribable pain. The long, slow breathing, she has realized helps. She is hopeful that everything will be fine, she is not worried about anything. The most important thing to her is that she is married. This child is not a bastard. He (she hopes it will be a son) has a father and hence a future.

At the entrance to the wards, she is allowed in without delay. The security people don’t keep women with protruding bellies and dancing feet waiting. She is ushered into the maternity ward. The admitting doctor gets her details. She is a first time mother. She doesn’t remember when she got her last period, like ninety percent of all the women admitted into maternity. Currently she has low abdominal pain, that begun about sixteen hours before she presented to the hospital. Her baby is kicking just fine but her water hasn’t broken. The admitting doctor notes that. She asks for the antenatal clinic book. She is handed a purple booklet which, except for the name, is essentially blank. ”Mama ulienda clinic?” She asks. The patient answers in the affirmative. How many times? Once. The reason why no test was ever done is because she was unable to go back a second, third and fourth time. The county health care workers were all on strike over unpaid salaries. She couldn’t afford the private hospitals because she has no insurance cover. And she couldn’t go to the next county hospital either because she had no bus fare.

The doctor performs her examination and realizes she is carrying twins. Her cervix is five centimeters dilated. She hastily draws blood, to check her hemoglobin level and do other basic tests like HIV testing, blood grouping, et cetera. Her HIV sero-status comes out positive, her hemoglobin level a mere seven. The doctor summarizes the patient’s condition; “a first time mother, who is anemic and HIV positive, carrying twins, never been on ARVs.” This is definitely a recipe for post-partum hemorrhage and other chaos.

She decides to look for blood for her just in case she develops post-partum hemorrhage. When she goes to the lab, the fridge is opened so that she can see for herself that there is no blood. Because seeing is believing. So the doctor goes back to the ward just to consider her options; take out her prayer beads and say a continuous prayer for the poor clue-less woman. Pray that she delivers safely. Pray that she doesn’t bleed excessively after delivery, or refer her to the next county hospital. Her cervix is now nine centimeters dilated. The first baby will be born about one hour from now. The next county hospital is one hour thirty minutes away. So referral is clearly out of question. but she still calls the hospital for the sake of it. But the person on the other end is so sorry they also don’t have blood. So the doctor goes back and sits in the maternity ward and waits for a miracle, the miracle of safe delivery, good health to the mother and the babies. Because she can’t have a maternal mortality. Mothers shouldn’t die when bringing a new life to earth. And also mothers shouldn’t die because maternity care is “free” paid for by the government. Our dear government!

Rabies

Raise your hand if you have ever been bitten by a dog.
Raise your other hand if this dog that bit you has never been vaccinated against rabies.

Move to the left if the dog that bit you was a strange dog…..

A small boy, about six or seven lay in the hospital isolation room, with saliva drooling down the side of his mouth. Occasionally, he suffered a strong seizure that made his whole body tense and shake at the same time, before slipping into episodes of apparent calm. His mother sat by his side, with hands supporting her cheeks. Occasionally, she would stand and pace the room, raise her hands and place them over her head before finally walking back and taking her place beside her son. He later slipped into a coma, and as we all know, this story doesn’t end well. When he had shown up in their house one evening three months earlier with bite marks and scratch marks thanks to a neighborhood dog, they decided the bite was too small and just ignored it. Three months later, he presented with full blown rabies. (This is a true story).

September 28th is rabies awareness day. Incidentally, yesterday I saw a woman who had been bitten by a dog two days before she presented to the hospital. She was admitted for reasons other than the dog bite. But I had to bring up that “small matter” of a dog bite. She didn’t have money to buy the anti-rabies, she promised to look for the money. Meanwhile, we will just sit back and pray that she gets the money….before it is too late because rabies is real.

Rabies is a viral disease that affects the central nervous system (brain), usually transmitted through a bite by a rabid animal.
Rabies is transmitted through a bite by a rabid animal, usually a dog. In my village, they are called t-nine, or mbwa wa kichaa. Other animals that can transmit rabies include monkeys, skunks, cats, wolves et cetera.
In the unfortunate event that an unvaccinated or a strange dog bites you, please make sure that you seek medical help. Go to the hospital and have the wound cleaned, get an anti- tetanus shot and get a dose of the anti- rabies vaccine. Now ideally, you should get five shots of the vaccine. The day you are bitten is the first time you get the vaccine. That is day zero. Then you should get a repeat shot on day three, day seven, day fourteen and day twenty-eight.

Of course most people rarely get the anti-rabies. The few who get it get a single dose on day zero and never return for the remaining doses. The issue is money constraints. The anti- rabies vaccine costs an average of one thousand five hundred shillings. Public hospitals almost always never stock it and most medical insurances don’t cater for it. So most people who present to the hospital end up skipping it altogether. The question is, if a dog bit you today, would you afford the anti- rabies vaccine right this moment? Maybe we should remind the forty seven county governments that they need to stock anti- rabies …

As a young girl growing up in the village, once in a while, we used to have mass vaccinations. A community vaccination of all domestic animals. I haven’t heard about them for a long time now. People are too broke vaccinating their domestic animals is the last thing on their mind.
Maybe the reason why we are a third world country is because we are still killed by diseases like rabies. Of all diseases that should kill us, rabies shouldn’t be one of them. But it is.

NB; on day zero, rabies immune globulin is administered together with the anti- rabies vaccine.

NIGHT SHIFT

3:00 hours.
The extension phone in theatre rings once. The theatre nurse stirs, but continues resting her head on the table. Her breaths are coming out in shallow regular spurts. She looks peaceful, comfortable even. The extension phone rings again. This time, the ringing is continuous. The harsh krr, krr, krr of the phone jolts her awake. She lifts her head. She is disoriented for a minute or two. she looks around, yawns, stretches her arms then stifles another yawn as she picks the receiver and places it next to her right ear.

“Theatre”, she croaks into the phone, then listens. “Okay”, she says and replaces the receiver. She has an operation to prepare for. She walks into the operation room and taps the other nurse. He is seated on a theatre stool, head resting against a wall. She taps him on the shoulder. He wakes up immediately. They start preparing the operation room for surgery. Then the extension phone on the nursing station starts ringing again. He goes to receive the call. He comes back just as the surgeon walks in. the anesthetist also walks into the changing room soon after the surgeon.

The second phone call is from maternity ward. They have two emergencies; two cases of fetal distress. The theatre nurse informs the surgeon about the maternity cases and the surgeon knows that his patient will have to wait and probably lose one testicle in the process. He has reviewed this particular patient. An eighteen-year old male with scrotal swelling and severe scrotal pain, admitted about an hour ago, a condition called testicular torsion. It is a surgical emergency. The earlier the operation is done, the higher the chances of saving the testicle.
At the entrance to theatre, the patient from maternity and the young male patient arrive at the same time, both wheeled in by nurses. they are both wailing in pain. One from labor, the other from a rotated testicle. Both of them have emergency conditions. But because there is only one theatre bed, only one of them can be saved first; the pregnant lady. She is carrying a life. So she gets in as the young man is wheeled back to the ward. He will be taken to surgery alright, but then he will lose his testicle. Because the longer the time taken to operate on a testicular torsion, the higher the chances of losing that testes.

Because of severe shortage of theatre staff and equipment, doctors every day have to make tough decisions. Every time you get three pregnant women in need of emergency cesarean sections, you have to decide who to take in first amongst the three. You are therefore indirectly deciding whose child to save now and whose to save later, something that doesn’t always work well. When you have done your best assessment, you might as well save all of them. But sometimes, “shit happens”. If you have a mother in labor who requires a c- section and a young man with a rotated testicle that needs to be fixed urgently, you will of course decide to save the mother and the baby and lose the testicle! Doctors are always playing god, not only on which patient who gets admitted into an intensive care unit, but also on who to be saved and who to deal with consequences.

You Must Not Lie To Your Doctor

When I caught my patient sipping some mysterious-looking fluid from a plastic bottle just three minutes before being wheeled to theatre, I remained motionless for a second or two. Then I casually walked towards him. He had to hide whatever it was that he was trying to drink. As I stood by his bed waiting for the nurses to wheel him to theatre, I couldn’t stop myself from asking him, “George, ulikula mara ya mwisho saa ngapi?“ “Jana usiku, kitu saa sita hivi”, came his reply. I chuckled. He looked up at me with the most innocent eyes I have ever seen. I was about to ask him another question but then the nurses had already arrived by his bedside, ready to wheel him to theatre.

Once on the operation table, the anesthetist asked him the same question, “boss, ulikula mara ya mwisho saa ngapi?” and he gave the same answer. But because anesthetists are anesthetists, he asked another question, “hata maji haujakunywa? “and he said no. I had to walk out of the operation room and wipe the grin off my face before the anesthetists could see it and demand for some explanation. You see, I knew George was lying, but I chose to say nothing. I had done the exact same thing George was doing now some six years ago. I had been scheduled to go to theatre at seven in the morning. The doctor’s instructions were; to take nothing by mouth beyond midnight, when I became a doctor, I learnt a fancy term for “do not eat anything” it is called being nil per oral! So I didn’t take anything. Then in the morning as I was being prepared for the operation, my parents asked for five minutes so they could pray with me (back then, going for surgery was euphemism for dying/going to die/about to die). They were granted the five minutes. And they prayed for me. Then they made me take a sip of some herbs from a bottle. And I sipped and I was taken to theatre and when asked the last time I had eaten, I said midnight. I didn’t even die.

Patients set to undergo surgery are routinely starved for about four to six hours, as a precautionary measure to prevent aspiration of stomach contents into the lungs. This could happen during general anesthesia. Doctors rarely explain the reasons for starving patients before surgery or the real dangers of eating just before surgery. That is why patients are always outsmarting doctors, like the way George and I did! We were just lucky though. The next time your doctor tells you not to feed before surgery, please don’t. Or if you happened to succumb to a little bit of temptation and had to take a slice of ugali and nyama choma, just let your doctor, or at least the anesthetist to know! If you want an uneventful surgery, you can’t afford to keep such things away from the theatre team!

Doctors Should Stick With Their Bad Handwriting

When Gabriel walks into the gynecology clinic, I am expecting that his wife will follow him into the consultation room. But he closes the door behind him and takes a seat . And no, he doesn’t have any problem really, just a small question though; “daktari, they say that my wife has an incompetent cervix“, he begins tentatively. So I look up at him and wait for him to ask his question. He regards me for a moment then goes on, “tell me daktari, how can a cervix be incompetent?’ I look at him closely for the first time, he looks like one of those men who go to beauty parlors for a facial. He has the smoothest face south of Sahara, and for a minute, I almost pass a hand over my own face. “cervical incompetence’, I begin, “means that during pregnancy, the cervix dilates and becomes thin before the pregnancy reaches term. The effect of this is pregnancy loss or a miscarriage”. He exhales visibly and I almost chuckle. I mean what did he think after seeing the diagnosis? I want to explain further but he is ready to take his leave. He extends his hand and I shake him while he mutters his thank yous then quickly leaves closing the door behind him. I try to imagine what he saw written on his wife’s consultation card. The correct term is “cervical incompetence” how did it become incompetent cervix? As the next patient walks in, I decide doctors should just stick with bad hand writing. Writing in a legible hand writing that patients and their relatives can easily read might give someone a heart attack soon. Imagine that man seeing incompetent cervix as his wife’s diagnosis? What was the first thing that came to his mind? Now imagine if that man decided to be unreasonable, arrived at his own conclusions and confronted his wife about it? Maybe he might have included it in his list of abuses; good for nothing woman, lazy, incompetent cervix, idiot.

NB; always ask your doctor to explain everything, you can’t form an opinion based on what you see. Sometimes, a list of words written side by side don’t mean what you think. Adios

It Could Be Depression

There was a time when reading used to make everything better for you. From fixing your broken heart, shortening a lengthy day, cooling your nerves just before an important interview and even uplifting your lowly moods. Those days, you could be passing through hell and not even realize it because books offered you a nice escape, to beautiful shores, Rocky Mountains, deserts whose air was laden with too much dust you wanted to cover your eyes with your hands by just reading about them. These days, you hardly enjoy a book. As a matter of fact, you are finding it increasingly hard to pick a book and start reading. Every time you talk yourself into reading one, you barely go through the first ten pages before the over powering urge to stop comes again. There are ten books all book marked at page ten that you have started to read in this past week alone but couldn’t go beyond the tenth page. You don’t get the kick you used to get from reading anymore. You have tried movies but realized every time you start watching one, your thoughts wander. The movie plays on till the end only for you to realize you have no idea what the movie was even about.

You can’t read, you can’t watch a movie, and as if this is not enough, you can’t seem to fall asleep at night. On those nights when you fall asleep, you can’t stay asleep for more than two hours. And on those days (which is every day by the way) you have nothing to keep you company apart from your own thoughts. You realize you would give anything just to run away from this hopelessness that has descended upon your world.
Three quarters of the time you are lying in your bed turning, tossing and even then, you don’t want to get out of that very bed where you lie gazing into space. Every time you push yourself to get up, the farthest you get is to the bathroom. Just to empty your bowels and pee, take a really quick shower on the day when you feel it is absolutely necessary, serve yourself a mountain of food and sit on the bed that you last made two weeks ago, and eat all that food. You have added a few inches to your waist, the clothes hug your body more, three skirts are threatening to burst at the seams. You know you are headed for obesity but that is the least of your worries now.

You know you are supposed to feel better in the morning but all days are the same old and dull to you. You feel as lonely on Friday nights as you feel every Monday morning. Your friends no longer call. They are tired of the lack of enthusiasm on your voice when you finally choose to answer their calls. You have missed friendship re unions with no explanation and they are tired of trying to pull you down from your high horse. Your mother has made peace with the fact that you are going to call home once in a blue moon. She is okay if you are okay. You don’t care about social media any more. You are tired of running into your ex everywhere in these streets of face book. You are tired of trying to tell yourself that he doesn’t deserve you. Probably you are the one who doesn’t deserve him with your body looking like a roto tank with all the eating you have been doing.

You feel so empty; you have a pain that you can’t even describe. You slap yourself. You want to feel physical pain. You wish for someone to come and beat you up. Or even for a matatu to run over you, break a limb, break something in your body, leave you in a coma where you will lie and wake up and scream over a physical pain.

You know whatever is happening to you is not even normal. You are in a place to the extreme left of sadness. If you could walk even a little bit, then walk yourself to the bus station and ask them to drop you at a hospital gate. Because you are depressed and if it is going to get worse, you will commit suicide…

Most of your friends aren’t even going to realize that you are depressed. If anything, they will accuse you of all sorts of things. Maybe we can’t blame them. We live in a society that has taught us that it is okay to be unhappy. That we don’t even deserve too much happiness. That we can’t blame anything in our lives for the feelings that we feel.