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