The Lost Post: What Gift Have You Brought?

This first post about the flight to Kenya and the first day there accidentally got deleted, now I'm reproducing it from memory.

Today I begin my journey to Kenya. I board the plane and watched the rainy basin of Puget sound fade away into the clouds.  Later we passed over the frozen plains of Alberta.  In the dark of the polar night we passed over the glittering fjords of Green land.  Soon the lights of London were below us.  Finally we landed in Paris at Charles de Gaulle airport.

Leaving Seattle

Flying over Alberta

A glimpse of Greenland

Paris before dawn

At 8am there was no sign of the sun; Northern Europe is much darker than Washington in the winter.  De Gaulle airport looks like a shopping mall, with high end shops such as Cartier, and a fancy cheese shop, very French. The flight to Kenya was delayed by 3 hours but finally we landed.

Fancy shops

Cheese counter

Flying over the alps

Lago di Garda and Towns of northern Italian plain 

This was another night flight and I noted the lack of electric lights over Africa below.  Except for Jedda on the Arabian coast the interior was mostly dark, with only a few lights scattered here and there. Finally we landed in Nairobi. The city lights end abruptly along a line marking Nairobi National Park, a place where you can see giraffes, elephants, and other megafauna mingling next to skyscrapers and markets. I passed the big "Karibu Kenya (welcome to Kenya)" sign and picked up my luggage.  After some confusion in the crowd outside arrivals I met my driver Felix and he went to get the car.  In the meantime I struck up a conversation with a police officer who was watching over the ground transportation zone.  I was excited to have a chance to finally practice Swahili after months of study.  We mostly talked about travel and life in Kenya; eventually the conversation changed and he asked me "what gift have you brought?".  I answered that I've brought the gift of knowledge, medical knowledge to be precise.  After my work here is done there will be 2-300 Kenyan people whose health will (hopefully) be improved through my services.  I'm not sure that was the answer he was looking for...he pivoted and asked me to buy him a coffee (this phrase, I learned, is a covert way to ask for a tip).  I handed him a couple hundred shillings (about $2) for helping me practice Swahili.  Soon my driver met me and we were off. 

Karibu Kenya 

Welcome home

The night in Nairobi was quiet, hardly anyone on the street.  Street signs all in English, easy to understand.  We reached Chaak guest house, I checked in and immediately went to bed.  In the morning I awoke to the sounds of singing birds and explored the hotel courtyard, which was filled with fragrant flowers. At breakfast (hearty starches and meats washed down with masala chai) I chatted with a Kenyan fellow about work and politics. My next driver John came and we began the journey to Kijabe. I had to pick up the house keys from Jason, who was staying at a hotel in Nairobi.  We met in the lobby and exchanged news and information regarding the rotation and our respective future plans. He's planning to have a market day in Nairobi then head to Maasai Mara. We bid our Bon voyages and went on our way.

Chaak Guest House courtyard

Next stop was a grocery store. I was quite optimistic about the amount of cooking I'd be doing, and so loaded up on spices and vegetables, and other things like canned beans and breads.  Next it was time to head to Kijabe.

The Nairobi-Kijabe Road slowly turns from urban to rural. City streets turn to suburbs, then small villages and farmsteads open up.  Cattle, goats, sheep, and ducks graze by the side of the road. Market stalls line the high way backed by concrete structures filled with shops and apartments. The people get around on foot, motorbike, car, or matatu, minibuses which are often painted with colorful murals. Occasionally I'd see a car racing in the opposite direction with a bag of green plants on top.  John explained that these cars are carrying mera (qat) to market. This stimulating herb is grown in the fields and must me transported quickly to markets in the city while still fresh.  Therefore the drivers delivering this good must drive at breakneck speed, sometimes recklessly! We continued on through landscape of rolling hills and farming villages.

Suddenly the ground fell away to the west and became a massive deep valley: we had reached the Eastern or Gregory Rift, a giant gash in the Earth's crust reaching from Malawi to Lebanon where the Nubian (African) plate is pulling away from the Somali plate.  This region has given rise to volcanic activity, saline ribbon lakes with no outlet, and a distinctive hot savannah climate with unique ecology. I hadn't realized it was so close! We stopped momentarily to take in the view and marvel at the size of the rift, then continued on.

Cloudy rift valley

We rounded the hill to reach Kijabe and began the descent to the town, which is midway between the level of the highlands and valley floor. Kijabe hospital was built at this spot because it is too high/cold for the malaria mosquito to complete its lifecycle.  Kijabe itself is a small farming town of dirt roads with a few basic amenities: shops, restaurants, a gas station; quite different from the comparative metropolis of Seattle.  Nevertheless, the people seem friendly and welcoming here, and there is a recognizable small town atmosphere.  John and I finally reached the house and I dropped my stuff off.  The house (apartment) is 3 bedroom one bath, on the third/top floor, with a giant window overlooking the Gregory rift.  It's going to be quite an experience looking out each day over the likely place of origin of the human species! The apartment is tastefully appointed with African style decor and mostly natural (I.e. wood) furniture.  A lovely place to spend 3 weeks! After a couple hours lounging, Rochelle (my supervisor), Natalya (her daughter), and Ginger (Rochelle's mother) returned from their trip to Lake Nakuru.  Now the rotation could truly begin! 

A good policy

Cozy abode

Wrapping up: A Portrait of Kijabe

 Since returning from Mt. Kenya I've been taking the opportunity to rest and recover from the journey.  This is my final week in Kijabe before I head to Nairobi next week and start a one week safari/beach vacation. After such a big adventure I've dedicated myself to the simple pleasures of home: cooking, lying on the couch, reading, writing, walking around town. 

During our work this week we encountered a rather unusual case. a 35 yr old female with non-tender left scapula mass measuring 14 x 8 cm for 3 yrs which is soft, mobile and not attached to underlying tissue. Ultrasound also revealed multiple solid masses at the posterior of T8 measuring 4.4 cm and 2.2 cm. Clinically, they thought this was a lipoma. Grossly, the excised left upper back mass appeared as a tan yellow encapsulated lesion with tan-yellow to tan-white fatty to myxoid/gelatinous lobular firm cut surfaces.  Here are the microscopic images:

Spindled cells with cigar shaped nuclei, mild to moderate atypia

A hypercellular lesion for what we thought was a lipoma..

Focal palisading, suggesting possible nerve sheath origin

We ended up sending this case as a consult to UW.  One of the BST pathologists there agreed that this could perhaps be a nerve sheath tumor, likely a schwannoma.  The atypia might be degenerative atypia (ancient changes). 

Aside from that case I've fallen back into the routine of previewing cases in the morning, handing them off for later review by the attending, and grossing in the afternoon.  The workload has been light.

Other highlights of a peaceful week in Kijabe:

Rift Valley Sunset

Locals will turn anything into a plant pot, including old bottles of cooking oil!

IHC is performed in this pressure cooker; UW lab procurement staff take note: next time we need new IHC equipment a trip to Wal-Mart may suffice! 

Shipping containers as structural elements at the local university

An abundance of delicious fresh fruit

This fellow's bike has a leek, several actually...

A portion of tissue that looks like Africa...

An unusually large amount of potatoes on the patio

Trying out the restaurant at the local gas station (recommended by Phillip): stewed chicken, ugali, and greens

A path leading downhill opens to a view of the rift valley

Exchanging gifts on the last day: a heartfelt goodbye to our colleagues at Kijabe hospital.  Kwa heri, tutaonana tena (goodbye for now, we will meet again!)

Climbing Mt. Kenya Part 3: Encountering Kirinyaga

 

The 2:15am alarm went off far too soon.  I attempted to snooze for a few minutes and deny the fact that I had to get up, but before long my fellow bunkmates, mountaineers from a dozen different countries, began to rise and get ready for the voyage ahead.  I packed up my things and headed to the main hall of the mountain hut, bleary eyed and dreading the climb ahead.  I took prophylactic ibuprofen and diamox to stave off the altitude sickness and ate a small snack of popcorn and biscuits, the most anyone could reasonably stomach at such an ungodly hour.  Soon Sam and Phillip appeared, we organized our things, and then set off into the pitch black beyond Shipton's camp. 

Climbing in the pitch black

The stars wheeled overhead, and we were surrounded by the shadowy forms of the giant groundsels, whose massive green leaves would sometimes be illuminated by my headlamp.  Soon we started to climb the steep ascent to Lenana, the "easiest" of Mt. Kenya's 3 peaks at "only" 16,355 ft. The way was difficult, incredibly steep and with much scree.  Phillip offered a lot of motivating words, encouraging me to take things one step at a time, and this advice turned out to be essential to making it up the mountain. Slowly the large groundsels vanished, and only tiny weeds were left for vegetation, then only fuzzy lichen eking out a living in the rare mountain air. For 2 and a half hours we crawled up the gravelly slope in the inky darkness, with no sign of our destination, or of the coming of dawn. We had now climbed so high we could see over the valley walls to see the glittering lights of the cities surrounding Mt. Kenya, a hundred miles away. Eventually we reached a sort of flat area with rocks.  I thought that was the peak, but the same pointed up at a sheer rock face above us: that was the peak, we still had another 400 feet to go.  It seemed like an impossible task.

Dawn

Morning light

I actually had something like a mini panic attack when I realized how much further we had to go.  I was convinced that my legs were going to give out on the way back down and I'd plummet off the side of the mountain to my death. To make matters worse, the incline was even steeper on this part of the mountain, and the gravel was more treacherous.  All the same, I managed to keep a clear head and we ascended higher onto the mountain.  Pink ribbons of light in the east signaled the coming dawn, and I could finally see the behemoth of a mountain that I was climbing up. Just before reaching the summit, we encountered snow caps, the crown on Ngai's creation; we were approaching the home of a god. 

We rounded the corner and were met by the sight of a small round glacier below, and a view of Batian, Mt. Kenya's tallest peak: an intimidating spire of volcanic rock towering beside us. A metal rope helped us ascend the last few dozen feet: the world's tallest via ferrata! There were a small group of people at the top of the summit, laughing and cheering in the now bright morning sun. Sam, Phillip and I soon joined them. We took our obligatory photos and took in the view of the immense landscape around us. 

World's highest via ferrata

Looking towards Batian

Sunrise

Moonscape

Success

The way down was precipitous, and we all slipped more than a few times. The view was spectacular in the morning light: we could see everything for hundreds of miles. Eventually we reached a small flat rocky area next to a tarn where we recuperated, had a snack, and let the relief of finally having conquered the mountain set in.  Our next step was to rendezvous with Rochelle, Natalya, and the other guides for brunch. 

Looking down the mountain

Carefully descending

Looking back at the peak

Mars-scape

Tarn

We steadily made our way down the rocky cliffs until we reached the brunch spot where I promptly found a comfy rock and took a nap. I awoke shortly as Rochelle, Natalya, and the others arrived. We ate our brunch heartily, but Rose, Sam's daughter who had come along as a porter, had come down with a bad case of altitude sickness and was not able to eat or drink anything.  She would have to descend the mountain with us, that was the only way her altitude sickness would go away. 

High alpine views

Descending to the brunch spot

Mountain lake

Brunch spot

After some time, we once again packed up and began our respective journeys: Phillip and I would go to Chogoria, and Rochelle and Natalya would keep climbing up to Nelion. We bid our farewells and good lucks and continued trekking down the mountain. We passed back through the forests of giant groundsels, and through some lush meadows with trickling streams.  we passed by other porters and campers on their way up the mountain.  Periodically Rose needed to stop to rest due to her symptoms, and I gave her some tums and ibuprofen periodically to make it easier for her to keep hiking.  

Descending back to Groundsel-ville

After weaving up and down several valleys on a large plateau we turned west and descended into a cirque, and old glacially carved bowl shaped valley that has now turned into a muddy bog.  This cirque where a glacier once stood plunged down into an immense V-shaped valley with sheer rock cliffs hundreds of feet tall. Alfred, our assistant guide, noted that this was the "Gorges Valley". We continued hiking until we descended back down into the Chaparral. At this point our oxygen levels were replenished and our energy levels were improving. we were walking down a very very long ridge of the mountain and in the distance we could see vast green rolling hills, valleys, and the peaks of other dormant volcanoes. I had gotten to chatting with Alfred the guide about Kikuyu culture and life in Kenya.  He pointed to a tiny white speck in the distance and stated that this was our destination. After nearly 12 hours of hiking already this was not welcome news...

Misty valley

Hooray!

Gorges Valley

Cliff walls

our destination: that white speck

Vast open country

Tranquil stream

we continued trekking through the Chaparral and periodically peering into the Gorges valley, which was unbelievably spectacular with its lake, waterfall, river, and sheer cliffs. eventually we reached the bottom of the crossed a large, crystal clear river which must have it's source in Mt. Kenya. we rested a bit by the river campsite and had a small lunch of potatoes and noodles. Phillip then informed me that is was only 7 km to our destination (only!). We walked along a wide dirt road through rolling hill country filled with small birds darting about.  Phillip was getting nervous as it was getting near dark, and animals would be stirring soon.  Luckily, a pickup truck came along and offered us a ride to our destination. We shortly arrived at Ambas lodges, a set of cabins just inside the national park boundary.  We could finally wash off the crust of several days of backpacking and put our feet up by the fire.  It was good to be back in civilization.  Phillip and I both collapsed early that night, but not before listening to the eerie barks of hyenas outside the cabin.

Finally at the lodge