current projects and documents

This is a resource and orientation blog site for residents and students visiting the FACES-Nyanza clinical sites in Kisumu, Suba and Migori, Kenya. We will include our reflections on the rotation, details about travel, housing and food logistics as well as all the current projects we're working on. Currently this blog site is maintained by UCSF residents in internal medicine, but we welcome residents and students from all departments and institutions visiting FACES from abroad to utilize and participate in it.

To see the current projects, which are updated regularly as Google live documents, you can go to www.gmail.com and log in to the email address: FACES.CME.projects@gmail.com with the password: karibu

Click on the “documents” link on the top left of the web page to view the list of documents. Click on each document to see the most recent version of it.

To be able to post blogs and edit the current projects, please contact sophy.wong@ucsf.edu to get the instructions for access and passwords. Please also include in that email request your name, institution, title or year in school, dates at FACES, and role at FACES.

visa for Kenya

[last updated 2007 Aug 9 by sophy]

-in advance (most reliable but not necessary): give it at least a month, need to send passport, 2 passport photos, visa application Form V, $50 for single entry up to 3 months, certified return envelope [kenyaembassy.com, check LA office]

-upon arrival: pretty easy and more reliable than in the recent past; during busy seasons and arrivals, prepare to wait at least one hour, have the above items ready ($50 cash and visa application from the airport - you don't need the Form V; photos may be needed but may not be), and beware of corrupt officials asking for bribes. If you get asked for a bribe, then ask them to speak to a supervisor. That should put an end to the bribe request.

travel to Kisumu / Kenya

[last updated on 2007 Aug 18 by sophy]

Summary:

•You want to check for flights that go to Nairobi (NBO). British Air offers direct flights from SFO to London, then London to Nairobi. KLM offers flights from SFO to Amsterdam, then Amsterdam to Nairobi. There are also now flights from Paris.

•

•From Nairobi you will either purchase a ticket there for a flight to Kisumu (40 mins) or take a taxi into the city and take a bus to Kisumu (8+ hours).

•

•Contact Kimberly Bale <BaleK@globalhealth.ucsf.edu> at least a week before you leave with your flight information and plan for travel from Nairobi to Kisumu. Veronica Achieng will pick you up from the airport or bus station and arrange transportation to the FACES flat or the Pabari Cottages, depending on where you are staying.

•

*** More suggestions, updated 18 Aug 2007:

-prices for flights fluctuate dep on season, but expect to pay $1600-1900 for SFO to Europe to Nairobi and back. On off-season (Feb-April), you can find tickets as low as $1200. This is going to be the biggest expense on your trip. Purchase tickets to Nairobi, not directly to Kisumu. i generally call STA Travel, check in with them about pricing trends, and also check out British Air and KLM websites.

Suggestions: try the following online resources for your flight to Nairobi...

http://www.kayak.com - as a clearinghouse for most major online sites (thanks, Kate!)

http://atmtrvl.com/ - a local SF travel agent that Craig Cohen uses, call 415.627.0717

http://www.statravel.com/ - student travel agent, may have special discounts, best to call them for specials (800) 781.4040

Specific airlines that fly to Nairobi:

http://www.britishairways.com

http://www.klm.com

http://www.virgin-atlantic.com

-bag limits are strict from London to Nairobi (one carry-on only, 2 bags at 25kg max each baggage limit) and from Nairobi to Kisumu (if you fly, 20kg max weight for checked bags *total.* they don't weigh your carry on unless it's huge. some airlines will allow you to fudge to 25kg if other people on the plane don't have much stuff). so if you are hauling a lot of stuff, i.e. more than 25kg, you should think about taking a bus instead.

-flights from Nairobi to Kisumu: most people have a half-day or overnight stay in Nairobi and have time to purchase their tickets when they get there. It's really easy to purchase there, and you almost always get a seat. If you prefer to have them in advance (pricing is similar online), you can try purchasing them online with Fly540 or Kenya Air. Their websites seem to work only intermittently, so i tend to purchase the tickets when i'm in Kenya. The flights should cost $40-50 each way on Fly 540. Kenya Air is much more expensive, at about $70-80 each way. There's another small company that also runs a plane shuttle- i forget what it's called, but the prices are comparable to Fly540. For all airlines, there are generally one set of flights in the morning, around 8 am, and one set of flights in the evening, around 6-7 pm.

http://www.fly540.com/

http://www.kenya-airways.com/

-if you need to stay overnight in Nairobi, some recommendations on safe places to stay (take a taxi and don't walk around at night, esp by yourself!):

budget ($5/night) - YMCA hostel: Y.M.C.A. Shauri Moyo Hostel, Ambira Road, PO Box 17073, Nairobi, Kenya, Phone : +254 (2) - 558383, Fax : +254 (2) - 728822

moderate ($40/night): Comfort Hotel, in the city centre: http://www.kenyacomfort.com/

luxury ($100/night): Fairview, out of city centre but gorgeous: http://www.fairviewkenya.com/

-bus from Nairobi to Kisumu: no baggage weight limits, so if you have a lot of stuff, you're up for an 8-hour adventure, don't mind being the only non-Kenyan on the bus, and want to save a bunch of money, you can take the $7 bus from Nairobi to Kisumu. There are a few bus operators, but Easy Coach is the safest and most comfortable (but the slowest). Matatus are much faster and cheaper, but they are more dangerous, and i think the university is discouraging people to take the matatus... personally, i also think that it's even less safe when you are carrying a lot of luggage as thefts are more common on matatus.

At the airport, get an official taxi (with an official taxi number on the window and door) and ask them to take you to the Easy Coach Nairobi station. It's different from the main bus station, which can be hellish chaos. Protect your luggage! Purchase your ticket there and wait for the next bus. Make sure you pee and get food before you board (there will be one or two stops only on the 8-hour ride). The bus may be hot and usually crowded, but since you will be at elevation, it won't be too sticky. Keep your bags on your lap at all times or if you stay awake, keep them overhead and watch them (don't keep them on the floor; they run the risk of getting knifed). Bags in the trunk area of the bus are generally safe because they are monitored by the bus staff, but nothing's ever guaranteed while traveling, regardless of plane or bus. Time on the bus depends on road conditions: 6 to 8+ hours. Try to give Veronica Achieng a call along the way so she knows when you're arriving: pay someone to use their cell phone or call at a rest stop "pay phone" - i.e. pay someone with a special landline to make a call.

Make sure Kimberly Bale knows how you're arriving to Kisumu so she can tell Veronica Achieng where to pick you up! BaleK@globalhealth.ucsf.edu

Update 11/27/07 by Kate

-Airlines that fly from Nairobi to Kisumu are Kenyan Airways (you can buy online in advance, but is more expensive, ~$105 one way). I booked in advance so I could minimize my layover in Nairobi and it worked perfectly - made the 8am flight after getting in on the 6am ft from London. Fly540 is cheaper & has a website, but I haven't tried it and am not sure how well it works. East African and JetLink are the other common options. Both are cheaper (about half the price of Kenya Airways), but I'm not sure about advanced online booking. You can try contacting a local travel agency (Let's Go Travel in Nairobi has been highly recommended) and trying to arrange your ticket through them before you get to Kenya. If you're going to arrange your transfer after arriving in Nairobi, be aware that last month not all flights were going daily and it was a little harder to just walk up and be sure there'd be a seat that day. May have changed by now, though.

- Also, for in-country it appears that if you have >20kg of stuff it's ok as long as it's in 2 bags, neither of which is more than 20kg.

accommodations

Currently residents and students stay at the FACES Flat for $60/week. Coordinate with Kimberly Bale and Veronica Achieng on the payment and for housing dates. Kimberly can be reached at BaleK@globalhealth.ucsf.edu and Veronica can be reached at

vachieng@kemri-ucsf.org

The FACES Flat is located 1 block south of the Hare Krishna temple off Butere Road in Milimani, behind the Milimani shopping row on Nzoia Road. It has a gray gate that allows cars through. The flat is on the top floor, closest to the street. Keep in mind that most drivers don't know the names of the roads in Kisumu, so it's best to say something like, “one block down the street from the Hari Krishna Temple in Milimani, on the left”



Updated 11/29/07 by Kate

To tell boda or tuk-tuk drivers where to go, I found no one had ever heard of the Hare Krishna temple. Much better was "the new flats on the street behind Xaverian Secondary School". Worked every time. The shops on Nzoia Rd are the Kilimani shops, but the neighborhood is called Milimani.

The FACES flat is pretty nice; it's a 3-bedroom place with 2 bathrooms (one opens off one of the bedrooms), living room and kitchen. The kitchen has a fridge, sink, and cooktop burners (no oven). There are pots & pans and dishes, so no worries about that. When I left there was a lot of staple food (rice, lentils) that were recently purchased; on your way to the flat from the airport Vero will likely take you to the supermarket, so hold off on buying that stuff until you see what's left at the flat. The living room has a TV & VCR with a huge DVD collection (not all of them work in the African-system DVD player, but there's enough to keep you occupied on slow days). If you bring your own movies, you will likely not be able to play them on the VCR but you can on your computer. The bedrooms have sheets & blankets, pillows & mosquito nets. There are a few towels in the flat, but I'd recommend bringing at least a quick-dry camping towel. If there aren't any big towels for you to use, you can always buy one at the Nakumatt.

At present there is NO internet in the flat, to get access you need to go in town to Oginga Odinga Rd (expensive for wireless). There is free wireless internet in the residents lounge on (I think) the 5th floor of the Imperial Hotel. There is also a coffee shop ("the Italian Coffee Shop") on the second floor of the Universal Mall at the end of the road leading to FACES (the mall where Tusky's is). The coffee shop is upstairs next to the movie theater, they will give you the password for the wireless and you can use it as long as you want if you're a customer. There is wireless at FACES, also, which was a bit unreliable when I first arrived. It's very slow for downloads, etc, so if you think you may need articles or references, put them on your computer before you go. The FACES wireless is quite slow during the work day, so I usually got there early to email, skype, etc. DEFINITELY bring your computer!!

rotation pocket guide

[last updated 2007 Aug 7 by sophy]

Download the complete rotation pocket guide here:

www.resister.info/FACES.rotation.pocket.guide.pdf

It includes the rotation schedule, weekly clinic schedules, rotation goals, FACES formulary, WHO staging, contact information, etc.

map

Download a printable PDF map of Kisumu and Western Kenya here:

www.resister.info/kenya.map.pdf

what to bring

In Kisumu, there are huge Target / Wal-mart-like department stores where you can buy most common modern household items (except your personal meds, glasses, contacts, modern electronics), so don't panic if you've left something at home. They are in Kisumu: Nakumatt, Ukwala, Tusky's... but not in Suba, so buy your wares before leaving for Suba if you're going there.

In addition to the usual stuff, here's what you can bring particularly for the rotation/FACES:
-laptop so you can do your work, develop PowerPoints, and get online without competing for a FACES computer while you're there

-your own equipment: stethoscope (for sure), pen light, reflex hammer, pocket hand sanitizer (it's really hard to find clean water to wash your hands with regularly); consider bringing an otoscope/opthalmoscope to donate

-donations: Sanford's HIV handbook, pharmacopias, stethoscopes, pulse ox (finger machines), otoscopes/opthalmoscopes, HIV textbooks - check in with Kimberly Bale on which ones they might have to bring, hand sanitizer, PDAs, digital cameras, white coats

Download a possible trip packing list here (this is one i developed generically for all of my trips abroad but is applicable especially to trips such as this):

www.resister.info/trip.packing.list.pdf

travel: within Kisumu

last update 1 May 2007, sophy

on foot
-what it is: walking along the hot dusty roads; great for exercise and seeing the town!
-risks: watch out for crossing roads and vehicles that get too close to you (stick to the foot paths)
-cost: free!



boda bodas (bicycle taxis)
-what it is: Kenyan men (i've never seen a woman boda boda driver) riding big bikes outiftted with nice passenger cushions, handlebars and foot rests in the back; good for seeing the town a little faster and supporting microenterprise by young previously unemployed men.
-risks: no helmet, fast speeds downhill with questionable brakes, inconsistent bicycling skills- but safer than riding a bike without a helmet in China!
-how to find one: they are all over town, scouring the roads for riders; just hail one down on a decent sized road if one doesn't come to you quickly
-cost: 30-50 Ksh (30 in town, 50 to go a bit outside of town in Milimani)


tuk tuks (3-wheeled vehicles)
-what it is: a covered, motorized, diesel-powered vehicle with headlights and trunk space that can carry 3 passengers (though most try to fit more); good for relatively cheap rides home after shopping at the market or in town
-risks: no seat belts, small size means that a collision would be painful
-how to find one: mostly on the main roads in Kisumu, such as Oginga Odinga Road and Jomo Kenyatta Ave; you can easily find them next to shopping centers in town; you can also get the phone number of one if you ask a driver who now knows where you live (if he has a cell phone)
-cost: 50 Ksh in town, 100 Ksh beyong town (such as in Milimani)


matatus
-what it is: mini-vans with decent road clearance which provide most of the "public transportation" in Kenya, even though they are privately owned. Can carry about 15-20 people, though by Kenyan law everyone should have a seatbelt on. Used to cost 3 shillings, hence the name "tatu," which also means "three."
-risks: most people don't wear seatbelts, and they are frequently overstuffed with people hanging out the doors. There have been isolated cases of people getting thrown out of matatus that suddenly stop and having sever injuries (some fatal), which is why the seatbelt law happened in 2004).
-where to find one: matatu stand in town; certain main intersections on Oginga Odinga Road and Jomo Kenyatta Ave, such as the Mega Mall and United Mall
-cost: 10 Ksh in town; 20-50 Ksh beyond town, depending on where you're going


taxis
-what it is: like everywhere else, dudes (i haven't seen a woman taxi driver here yet) driving sedans. In Nairobi, stick to the official taxis with the circle logo on the car; there is no such designation that I know of in Kisumu.
-risks: getting ripped off by an unauthorized taxi
-where to find one: most folks in Kisumu have cell phone numbers of reliable taxis they call directly, such as: 0727-172-825 or Easy Cabs (director: George Kimani) at 0725-434485.
-cost: 100-200 Ksh in town; 200-300 Ksh beyond town, such as in outer Milimani


buses
-the safest bus companies that serve Kisumu include Easy Coach and Eldoret Express, which are fairly reliable but very slow
-these are mainly to get out of town, so refer to the other travel sections for further details

food: where to buy, eat out

last updated 1 May 2007, sophy

Purchasing food to cook on your own:

-ladies along Jomo Kenyatta Ave between Oginga Odinga Road and United Mall: sukima wiki (kale/collards) 10Ksh a bag, tomatoes, cucumbers, dried beans of all kinds, fish in various states of preparedness.

-Nakumat Market in the Mega Mall plaza on Oginga Odinga Road: almost like Wal-Mart, and can be just as crowded; has most of the packaged goods you would ever want. It also has a fruit and veggie mart in a smaller room next to it which is pricier than the outdoor market but not bad. Also has lots of imported fruits and veggies that you can’t get in the outdoor market (i.e. Asian stir-fry veggies, nice oranges, kiwi fruits, etc.).

-Ukwala Market on Oginga Odinga Road: has more Asian food items (mostly South Asian but has a decent selection of Chinese sauces).

-Tusky’s in United Mall on Jomo Kenyatta Ave: like Target and Safeway rolled into one. A very modern, clean, and relatively pricey (though cheap for US standards) supermarket.

-La Patisserie in the Mega Mall plaza on Oginga Odinga Road has great whole grain and other fresh breads.

-Kenshop bakery on on Oginga Odinga Road has a decent cookie and baked sweets selection.

Lunch at FACES Kisumu:

Most of us take a tea break around 11 am: the CIS break room has hot milk with Kenyan tea bags, and the stand outside sells sodas (300 and 500 ml) for 16 and 25 Ksh as well as mandazi (Kenyan donuts, which are basically unflavored fried dough), bread and popcorn. There is no water sold at the stand, and the water cooler in the break room is frequently empty. Bring your own water or walk to the Tusky’s at the United Mall to buy bottled water.

Most people take lunch at 1 or 2 pm, on a rotating basis so that there are always people at the clinic. Waya is a local woman who sells plates of food for staff. Veggie dishes cost 30 Ksh and meat dishes are 50 Ksh and up. You get to choose from the following elements:

-starch: ugali (white corn meal), white rice, chapati

-veggies: sukima wiki (kale/collards, literally, “push the week,” as it is one of the cheapest foods to buy), cabbage

-legumes: green grams (lentils), red kidney beans (“big beans”)

-meat: whatever Waya has for the day; i’ve never eaten any of it so i can’t vouch for it.

Other lunch options include walking to the United Mall for the semi-fancy restaurants at the casino or inside (expect to pay 350 Ksh, or about $5 US). The hotelis along the road in back of the United Mall also have lots of food stands. Beware of limited food options. Most of our Kenyan colleagues will eat only chips (soggy fries) and soda for lunch.

Restaurants in town that we like:

-Mon Ami: bar with decent restaurant with pizzas, Kenyan food, and lots of veggie options, a favorite local hang-out spot, which is fairly safe at night with DJ’ed music of various quality. It’s in the Mega Mall on Oginga Odinga Road. Expect to pay about 350-400 Ksh for a meal.

-Somi Snacks: in the Mega Mall plaza on Oginga Odinga Road is a South Asian mid-priced café style place specializing in vegetarian foods (!!) with excellent dhosas and juices. They also have pizzas. Expect to pay about 350-400 Ksh for a meal. Sophy’s favorite for veggie food options.

food: recipes

last updated 1 May 2007, sophy

Simple Chana Dal

for each 1 cup chana dal use the following:

1 cup chana dal or split peas, washed thoroughly and picked over for stones (no need to soak chana dal)

4 cups of water for cooking

1 large onion

1-3 tablespoons of vegetable oil, preferably canola, the more you use, the more moist it is

½ to 1 tablespoon of garam masala

salt to taste

2-3 tablespoons of your favorite sambhar mix for spice and flavor

1. boil the water in a medium to large pot (depending on your amount)
2. add the sambhar mix
3. wash and pick over the dal/peas carefully
4. put the dal into the water
5. add the garam masala and other spices
6. chop the onion into 3-5 cm pieces
7. heat up a tablespoon of oil in a separate pan or pot, and fry the onions with salt till nicely cooked and fragrant but not burnt
8. add the onions to the pot of dal/peas
9. simmer 30 minutes
10. add the remaining oil
11. simmer till the mix gets to the consistency that you like
12. Karibu chakula!

Sambhar (sophy’s version)

1 box of sambhar mix (you can buy it at Ukwala)

4-5 cups of water (4 cups for a thicker sambhar, up to 6 cups for a more soupy, stewy sambhar)

1 large onion

3-4 cups of chopped tomatoes (i.e 6 roma tomatoes)

the rest is totally up to you:

-vegetable sambhar: green beans, (already cooked) chickpeas and/or green peas, carrots

-meaty sambhar: add chopped pieces of your meat of choice towards the end of the stewing process; it may be better to cook red meat separately with oil and onion before adding it to the sambhar

1. add the sambhar mix to the water
2. boil the mix
3. add the onion and tomatoes
4. simmer for 10-15 minutes
5. add the vegetables
6. stew until you get the consistency you want
7. add any of the meats you want to the stew

cell phones

[last updated 2007 Aug 9 by sophy]

It's definitely worthwhile and recommended to have a cell phone while doing your rotation at FACES. It's the primary way to stay in touch with folks, including getting consults / feedback from medical officers, especially in Suba. You will SMS (text-message) A LOT.

-Kombo at FACES Kisumu (Lumumba Health Centre) has basic cell phones that you can borrow for free from FACES for the time you're rotating there. You just pay for the phone cards to charge the phones to make calls. These cell phones are pay-as-you-go. Kenyans call it "topping off" your phone.

-If you have a tri- or quad-band GSM phone, then you can ask your cell phone provider ahead of time to unlock your SIM card (you might need a password to unlock it), then purchase a SIM card in Kenya (it's not expensive, around US$10-20) and then purchase a pay-as-you-go phone card to put money on your phone. This is a nicer option if you particularly like your phone and it has a good texting keyboard. Be aware however that nice phones are more prone to theft; cell phone thefts are one of the most common petty crimes in Kenya.

rotation goals

[last updated 2007 Aug 9 by sophy]

Duration: 4-6 weeks

Rotation Goals

Learning objectives:

· Participate in a comprehensive model for the provision of HIV care in a resource-limited setting

· Understand the WHO HIV Clinical Staging system and the Kenyan guidelines for antiretroviral drug therapy

· Learn about the epidemiology of the HIV epidemic in Kenya

· Introduction to theory and practice of VCT, couples counseling, HIV peer education and adherence education

· Introduction to PMTCT (Prevention of Mother to Child Transmission) and pediatric HIV

· Participate in inpatient hospital rounds to understand the scope and limitations of inpatient hospital care in Kenya, and to assist in providing continuity of care for FACES patients who are hospitalized

· Participate in home visits and learn basics of Luo culture (family structure, marriage practices, inheritance issues) and their impact on the epidemiology of HIV

Teaching objectives:

· Bedside mentoring of clinical officers with focus on history taking, rational approach to the physical exam and generation of differential diagnosis and treatment plan

· Physical exam teaching; make it a point to pull in other nurses and COs to participate in a good exam

· Present one journal article relevant to HIV care in Kenya and review basic approach to reading the literature

· Present a CME lecture OR lead a post-clinic or noon-conference case discussion based on a patient seen with a clinical officer

· Develop 1-2 sections for the Clincians’ Pocket Guide to Medicine

· Complete a case report to be published on HIV InSite in collaboration with one of the FACES clinicians

Most importantly, have a great time!! It is an unforgettable experience.

Rotation “To-Do” List:

o sit in on at least one HIV education session

o sit in on at least one adherence session

o participate in in-patient hospital rounds

o participate in a home visit

o CME session (all-FACES/CDC staff lecture or case-based noon conference discussion with providers)

o Journal Club with relevant article

o Develop 1-2 sections for the Clincians’ Pocket Guide to Medicine, add to Google document

o Update the rotation schedule (this document), CME list, Journal Club list Google document

o Update the rotation blog!

o Upload your articles, PowerPoint

If you have a good case that you want to write up with a FACES CO or MO:

o HIV InSite case report write-up

rotation projects

[last updated 2007 Aug 9 by sophy]

Possible rotation CME topics and projects as requested by FACES staff (but always check in with the Google Live Docs CME/journal club list and FACES staff to make sure someone hasn't already done the one you're interested in!)

Rotation Projects and Topics of Interest

-compiled by FACES staff, last updated May 07-

-Change of ART regimen: Chart audit of the patients with change of ART regimen and document the reasons for ART change

-Death data- chart audit of patients who have died to document the CD4 count, WHO stage, reason for death , if they had been o ART and time to death after initiation of ART

-Structured observations of clinic visits to assess how prevention messages are incorporated in to the clinic visit based on what we think is our “Prevention with positives” package

-Development/ review of Paramedical staff curriculum

-Development of adherence counseling manual (expand on current SOP with more details)

-HIV education manual (expand on current SOP with more details)

-Tools for evaluation paramedical model (once indicators have been determined)

Default rates (and change over time as follow-up systems are put in place)

- Revision of site assessment tools

- Compilation of Desk job aid

-Mantoux test- current evidence on and recommendations of its value in diagnosis of TB

-What persons actually understand about taking meds when they leave clinic

-Clinic algorithms for common symptoms with broad differential diagnosis- goal would be to develop reasonable algorithm for differentiating and identifying and treating likely illness by history, exam and available investigations and medications.

E.g.-Chronic cough

-Persistent fever

-Persistent diarrhea

-Jaundice

-Hepatospenomegaly

Clinical mentoring on targeted history and exam based on common symptoms e.g. weakness, shorteness of breath, etc.

rotation schedule

[last updated 2007 Aug 9 by sophy]

Suggested Weekly Schedule

WEEK 1

Objectives:

· Understand the major responsibilities of each department

· Begin shadowing, seeing patients and mentoring Clinical Officers

Schedule:

Day 1 (plan to spend about 1-2 hours with each station in #3-9 below)

1. Orientation with Vero, Patie or MO/CO mentor: You should receive an orientation manual, a FACES formulary, a set of patient information forms, a list of drugs available at FACES, a copy of the National Guidelines.

2. Walk through clinic with receptionist

1. Vitals bench

2. Community Health Workers

3. Nurses’ bench

4. Laboratory

5. Pharmacy

6. Clinical exam rooms

7. Washrooms

8. Food places

3. Reception: Introduction to scheduling, types of patient appointments and relevant clinical forms

4. HIV Education session with Peer Educator/CHW

5. Triage nurse: WHO staging and initial triage, enrollment

6. Adherence Counseling: try to sit in on at least one of each; they happen in the mornings

7. Community Health Workers bench: Approach to triage, food by prescription

8. Nurses’ bench : Observe triage, follow-up, stable patient, & counseling visits

9. Sit in on patient visits with CO and MOs. Ask the CO-in-charge whom to sit with.

Days 2-5:

· Sit with clinical officers and begin to provide clinical mentorship. Focus on detailed history taking, rational physical examination, differential diagnosis, assessment and plan.

· Review the Kenyan guidelines for anti-retroviral therapy including first-line and second line therapies, indications for changing regimens, algorithms for lab monitoring

· Become comfortable with clinic logistics: how to order tests, prescription forms, FACES formulary, how to complete a clinic visit form, how to coordinate follow-up for urgent cases and labs/imaging

· Schedule your CME and Journal Club sessions with the CO in charge of CME scheduling.

Weeks 2-4 or 2-6

1. Continue clinical mentoring, physical exam teaching; also see patients independently if interested

2. Choose and prepare journal article

3. Develop CME (ask CME coordinator for topics that have been requested)

4. Write 1-2 sections for the Clincians’ Pocket Guide to Medicine (these can be the same as your CME topic)

5. Update rotation schedule, CME/Journal Club lists, and blog for fellow residents!

6. If you have a good case: choose and prepare case presentation or case report with a FACES clinician

Other Clinical Opportunities in Kisumu:

1. Prison visits with clinical officer third Thursday of every month

2. Attend VCT outreach session with youth teams from Tuungane

3. Visit FHOK Meshack clinc - outreach to commercial sex workers

clinic schedule: Kisumu

[last updated 2007 Aug 9 by sophy]

•Monday: 8:00 am – 5:00 pm Lumumba Clinic

•

•Tuesday: 7:30 – 9am Tuungane meeting, then clinic

•

•Wednesday: 8:00 am – 5:00 pm Lumumba Clinic

•

•Thursday: admin, CME and home visit day

7:30am – 8:30 am Clinical Meeting / Journal Club

9:00am - 10:30am Staff meeting

11:00am - 12:00pm Community Care Meeting

12:00pm - 2:30pm Home visits and hospital rounds

3.00pm – 4.30pm Continuous Medical Education

•Friday: 8:00am - 5:00pm Clinic hours with special emphasis for expectant mothers and children (but there are plenty of adults to see).

clinic schedule: Suba

[last updated 2007 Aug 9 by sophy]

Islands:

•Mon- boat to Mfangano, Sena Clinic;

•Tues- boat to Ringiti, Ringiti Clinic;

•Wed- Sena Clinic or Ugina clinic;

•Thurs- Remba island;

•Fri- Sena CME and staff meeting

•

Sindo:

•Mon- Sindo Clinic (peds day), or Mbita or Ogongo;

•Tues- Sindo Clinic or Kitare;

•Wed- Sindo grand rounds and CME, or Mbita, or Magunga, or Tom Mboya;

•Thurs-Sindo Clinic or Mbita or Nyadenda or Kisegi;

•Fri- Sindo clinic or Mbita clinic (peds day) or Lucky Youth

places to hang out

safari and weekend trips

[last update 2007 Aug 9 by sophy]

*Kakamega Forest: highly recommended!

My one safari in Kenya – purely for fun – was my trip to Kakamega Forest. It’s one of my favorite places in the world. It is the only rainforest in Kenya, and it’s barely protected by the government. The Kenyans have formed an NGO: KEEP- Kenya Environmental Education Project, to help do some of the preservation and education in the forest.

Kakamega Forest is very close to Kisumu – only a 45-60 minute matatu ride away. It’s in between Eldoret and Kisumu, so it was perfect for me to stay in the forest when returning from my trip to Eldoret. To get there from Eldoret, you can take a matatu to Kakamega town, then a matatu-truck to Shinyalu. That will cost 140 ksh to Kakamega, then 60 ksh to Shinyalu. From Kisumu, take a matatu to Khayega (these are likely to be the matatus going to Kakamega town, just ask them), which is about 140 ksh. Khayega is a small town on the highway before you reach Kakamega town from Kisumu. At Shinyalu, you can take a boda boda for 50 ksh or walk a hot dusty road about 7 km to the Forest Rest House bandas (basic bandas for about 200 ksh a night) or 9 km to Rondo House (absolutely gorgeous Christian retreat center: full board with 3 meals per day in a shared room, though it likely will not be shared because it won’t be full, is 4200 ksh for non-citizen Kenyan residents, i.e. people who work in Kenya but are not citizens, like me). At Khayega, which is further from the interior of the forest than Shinyalu, it’s best to take a boda boda for 100 ksh to Rondo or Forest Rest House. KEEP also has some bandas to stay in, but I am not sure of the pricing.

Once you’re in the forest, you can hire a forest guide for 300 ksh per person per hike/walk. Joe Mamlin goes to Kakamega all the time and always goes with a guide named Ben. I went with a guide from KEEP named Gabriel, who runs the KEEP Education Program in 100 local schools on a volunteer basis. His only income comes from leading these guided walks through the forest. I tipped him handsomely in part for that reason, in part because he led me on a great hike up to the bat cave and Rondo Point. At 2,000 meters, climbing the hill as fast as Gabriel definitely gave me a challenging work-out. It was well worth it: the view from Rondo Point is spectacular. You can see all of Kakamega Forest, as far as Kericho and Kisumu. The bat cave was also very cool. I got to see baby bats. There also something very peaceful (though initially scary) about being in a dark cave with small bats gently flying around you.

Rondo is a beautiful place, and well worth the extra expense. It’s peaceful, has its own self-contained beautiful walks through the forest. The food is amazing and fresh. They will accommodate special diets too. It was so peaceful that I didn’t even mind all the missionaries there. In some ways, we are doing similar work. It was definitely the kind of reflective getaway I needed.

Kisumu: massage on call!

Violet Lugonzo is a trained massage therapist based in Kisumu who can do house-calls or arrange a room at the Imperial Hotel for massage services. She’s a good practitioner (and I’m fairly picky). She does a full body massage (front and back, including face and feet; nothing weird, no "special" massages as far as i know) for 500 ksh on house-call, 1,000 ksh at Imperial Hotel (to cover the room fee).

-what: hour-long, full-body or customizable pressure-point and tissue massage

-price: 500 ksh on home-call or 1,000 ksh at Imperial Hotel

-when: any day of the week, daytime hours (for Violet’s travel safety), call at least one hour in advance to arrange

-provisions: provide your own baby oil or massage oil, own surface (bed or floor), towel or sheet. You can also ask Violet to bring massage oil for you, and then reimburse her when you pay her for the massage.

-contact: Violet by cell phone = 0734-724-644

faces of FACES

Check out a slideshow of the fabulous staff at FACES:

faces of FACES

Suba: living logistics

last updated 2007 Aug 18 by sophy

*Travel to Suba

Travel to Suba can be challenging and long, especially with rain. There are no paved roads for a large part of the trip. Most people arrange transportation with the FACES drivers. There is often a truck or SUV going to Suba each weekend, as staff constantly rotate back and forth from Suba to Kisumu. It is possible to take public transport to Mbita, where the FACES flat is. You can take matatus from Kisumu or a matatu to Luanda and then taking a ferry to Mbita.

*Mbita ICIPE House

FACES housing in Mbita is at ICIPE, which stands for International Centre of Insect Physiology and Ecology

http://www.icipe.org/

See below for more details from a peds resident who spent more time in ICIPE.

On the islands, you will mostly be staying in Sena, where the staff generally stays. There’s a building there reserved for staff housing, and they are planning to construct a new building for housing in the summer.

*Food

Bring your own groceries! There are no large grocery stores in Suba as there are in Kisumu. There are very few vegetables aside from sukima wiki, cabbage, tomatoes and onions. The kitchen in the Mbita house is very usable for cooking your meals.

Mbita- folks like to eat at Elk Lodge in town. It’s upscale compared to other places in Suba but still very affordable.

Sindo- folks like to eat at the second restaurant to the right on the road with shops and hotelis (I forget the name). Good samaki (fish) – fresh with stew is excellent, there’s also fried fish which locals like. A meal of soda baridi (cold soda; bring your own water if you don’t want all the sugar), samaki (fish), sukima wiki, and ugali or chapatti costs 70 ksh.

Sena- the Kamakuji Restaurant/Lodge/Bar is really the only place to eat in Sena. Fortunately, it’s decent though salty. A veggie meal of beans, sukima, and chapati/ugali costs 30 ksh. For meat, add 20 ksh.

Suba: clinical sites

*Sindo District Hospital


*Islands rotation:
-Sena
-Ringiti


*Satellite/mobile sites on the mainland (Kisegi, Ogongo)