The final blog's down duh duh duhhh duh, duh duh duh duh duhhh

And here it is. The last blog. Some very short mostly non-work related lists about what I’ll miss, what I won’t and what the future holds (both for me and for Speech and Language Therapy in Kenya). So here goes, my last first things that spring into my head - it’s been quite nice rambling on with my thoughts and getting some lovely feedback to boot. So thank you for listening:


What I’ll miss

1. The people
Yes yes yes, I know it’s a bit of a cop-out but what I mean is actually less the great people I’ve met/worked with who I will also miss, but more the community spirit/general happiness I automatically associate with people from Kenya. Part of what I’ll really miss is the daily exchanges with people both known and unknown - “Habari?!”, “mzuri” - The equivalent of a hark back to how I imagine the olden days of people greeting each other jovially in the local community.

2. Lack of technology
Although it was an absolute saviour on many a night (laptop/internet) I honestly feel fair more relaxed without being around technology, feeling the need to constantly check e-mails/face book etc.. or more to the point wasting hours scouring through pointless articles and websites. I read more books in my 6 months out in Kenya then I think I have in the past 6 years and thoroughly enjoyed making a bit of time to switch off from technology to settle down with a nice cuppa and curl up with a book. Something I shall endeavour to continue whilst back (He says watching football on TV whilst typing away on a laptop with an iphone beeping away beside me).

3. The work
In a slightly selfish way, I’m going to miss the work for a few main reasons: Firstly, I’m not sure when I’ll be able to grab a job within speech and language therapy in the U.K and I love what I do and secondly, I feel like I made a bit of a difference out in Kenya and as many people have mentioned I have probably gained more experience and knowledge in the 6 months past than I will in my first few years of work. And I’m a geek for Speech and Language Therapy so loved having to do research across such broad and wide ranging areas, both Speech and Language related and not.

4. Being outside England
I’m a bit of a traveller at heart and find anywhere and everywhere infinitely more interesting/exotic than England I’m sad to say… So plonking down in a 3rd world country, with a culture I had not previously experienced, with very little support was something that I absolutely adored.

5. The food
Bit of a weird one as in general there is not so much variety in Kenyan foods. Let’s see.. Barbequed or fried meat, ugali (maize staple), sukuma (kale), cabbage, beans, green grams, chapati, samosas, rice… is pretty much it on the whole. But I loved it. Sure, at times I had huge cravings for all sorts (mostly cheese, sometimes odd random things  - mussels, pork pies) but really could have eaten chapattis, green grams and bbq meat forever. And gotten very fat.

Things I won’t miss

1. Getting hassled
Out in the streets. Outside my home. In my home. On the phone at 6 am. On the phone at 10pm at the weekend. There were some great advantages being a foreigner (especially when it came to work), but there were some huge disadvantages - mostly based around people wanting money/food, thinking because of the colour of my skin I’m rich or clients phoning me at all hours asking for money, wanting to date me (!) or asking when I will see them next/when will their child get better.

2. Mosquitos
See the first part of number 1. Hassle! Also being able to jump straight into a bed and not having my feet or head touching net is absolutely lovely. I’ve been home 5 days and still have a few itchy bites/scars/lumps remaining. Grrr.


3. Not having a fridge
No explanation needed. It’s pure joy being able to have allsorts of different food, being able to have cold stuff(!) and not having to eat everything immediately or have the same thing for dinner and breakfast otherwise it’ll go off.

4. Risk to life
I’m not over exaggerating when I say “risk to life” - you do get used to things and end up not thinking about it too much but there was on average a big matatu (minibus) crash that made the news every week or so with deaths and severe injuries.. I was taking one of these or sitting on the back of a motorbike/bike with a very unsafe driver in a very unsafe environment (no traffic lights, signs or rules of the road really) on average twice a day. It’s nice to feel a bit safer even though cycling in London is a bit dangerous! An anecdote to describe this nicely was someone who laughed at me when I said I failed my driving test. In Kenya there is no test - you just pay for a license pretty much. On a lesser scale, safety issues at night meant it was not advisable to go out after dark unless with a lot of people/in a very public place. The freedom of being back here is delightful.


5. Some of the scenes
As expected in Kenya there were some pretty difficult things that I saw that I will probably carry with me for a long time, if not forever. In many of the situations, some good came of many of these situations, whether it be a client “coming up”, families/staff learning more and working more efficiently together or other but equally in many situations there was no possible solutions or staff/families did not care or were not doing there job properly which proved to end in the worst scenario imaginable, death.

The future!

Kenya:
As it currently stands, there are a few universities in Kenya who are interested/enquiring about starting up a university course to train speech and language therapists :) The only course currently in East Africa started 3 years ago in Kampala, Uganda and from the ideas inception to the course producing therapists took in the region of a decade. Therefore although it’s brilliant that through X, Y and Z, speech and language therapy is getting noticed in Kenya it will undoubtedly take a very long time for a course to be active in Kenya as one of the primary issues is the government need to recognise the profession to provide funding for university courses and ultimately jobs within Kenya.
The remaining 2 speech therapists in Western Kenya will be toiling away until June but there will be another SLT/P carrying on some of the work I have started/set-up in Kisumu from the end of this month for 6 weeks :) additionally, come the summer months there will hopfully be another short-term volunteer who I am in the process of persuading to come to Western Kenya rather than Mombasa so fingers crossed! Lastly, I’ve been asked at the university I graduated from last year to do a presentation on my time our in Kenya so who knows, possibly there will be some interest in coming out like I did and there may be more continual support come September/August time with some luck! Please refer back to http://jonathanmlfagan.blogspot.com/2012/01/some-pictures-and-little-bit-of_6409.html
for some more facts and figures about speech and language therapy in Sub-Saharan Africa, particularly Kenya.

Me:

After eating far too much cheese and chocolate (I never thought there would be a day where I would say) the first few days I was at home.. I got straight back into work at a nursery school I previously worked at. They have been extremely lovely and I have been unbelievable lucky to have been given my previous job back until I get that magical job in speech and language therapy (a report on the BBC a few months back said only 20% of new graduates in the field get a job within the first 12 months :( ). So that has been absolutely great. Catching up with friends and family, having things to do in the evenings, enjoying the cold weather (though like a traditional Englishman I’m already complaining about it) and in general settling back into western life has been really nice so far. Hopfully it’ll continue and fingers crossed I won’t get itchy feet too quickly and I’ll get a job in speech and language therapy before too long.

For those of you who are interested and haven’t checked it out yet, there is a SLT/P E-book project I’m working on which is slowly but surely (hopefully) taking form - Please get involved if you are interested/can.

Last thing!

Thank you all for everything. I know I’ve done platitudes and all previously but I guess deep down I figure as blogs can’t always express emotions (and no emoticons are not good enough) repeating something enough times might make you guys think I mean it.

Loads of love and thanks for checking out my blog and supporting me!

Jon x

Top 3 songs played on Itunes shuffle whilst writing this:

1. The Lighthousekeeper - Get Cape. Wear Cape. Fly
2. Jolene - Ray Lamontagne
3. Floating Vibes - Surfer Blood

And that was 6 months in Kenya: A round-up.

So. 6 months has absolutely swooshed by and I’m currently in Nairobi doing some last minute shopping, getting some last minute hassling and having hot showers for the first time in one and a half months :) (flight out is tomorrow)

This is just gonna be a update/round up of workstuff and then when home I’m gonna write a little thing about what I learnt, what I’ll miss, what I won’t etc..

The past week or so has been very much a wind-down although has almost seemed as stressed as any other week of work! I only pencilled in 2 days of clinical work, a couple of days for writing up things and a couple of days to whiz around all the schools, clinic and hospitals I’ve worked at to deliver packs of information so there is something in place to continue to refer to and photocopy for parents/staff/clients.

Most of my time was spent in the hospitals and like most hospital days there were ups and downs:

Three of the clients I mentioned last week (in the bit about how great parents/spouses were) passed away. Two of these were expected, however one of the clients, E (14 years old), on the face of it was “coming up” as they like to say here, putting on some weight and being more alert to her surroundings. I asked if they knew the cause of death but the nurses did not know and said a post-mortem hadn’t happened yet. I’m not sure if post-mortems are common here and have a small suspicion that as with a previous patient a post-mortem will not happen and no official cause of death will be determined.

The now famous paediatric Client C has put on weight for the first time in approximately 4 months - the duration of his hospital stay. Additionally he is continuing to be very alert and awake every time I see him. Both these things are a huge turn-around to a few weeks ago. To follow on my feelings from last week (and I’m not blowing my own trumpet - just making a point I feel very strongly about), without my intervention C would still be sleeping/not alert almost all day, every day and his weight would not have come up which is vital for how underweight he is and the energy he needs to relearn things by being awake. To promote the point for the umpteenth time - this stuff should have already been taken care of my members of the MDT (multi-disciplinary team) and I am pretty sure it wouldn’t have been either. This is my feeling with a few specific clients I’ve worked with - that bottom line without me being around they would have died. And this just isn’t good enough - the state of some of the hospital care/knowledge, as mentioned in the last blog.

Considering C constantly has seizures and fevers which affects his swallowing function, I felt (and explained to mum) that considering the next therapist who may be able to check in on C will likely not be for 3 weeks or so I would not be happy to do a swallow assessment and give advice to start oral feeding (should the swallow be good) considering his swallow function could go down/become unsafe at any point due to his condition. However, on my final visit to explain everything to matron (which I started to do shortly after starting work at both hospitals), she told me that she had seen Client C’s mum had started to feed him small amounts of food orally.  It is always the job of the therapist to give information for client/carers to make an informed choice. C’s mum has a great understanding of English and has been truly amazing in her dedication to NG Feeding (with her recent acquisition of feeding charts she drags me over to look at them like a schoolgirl who has gotten an A* on a test!) and I feel she understands the risks of feeding and is likely doing it as she is in the knowledge that the longer C does not use his swallow, the harder it may be for him to reacquire it (I explained this) and for him to enjoy tastes. The BRILLIANT thing (Highlight of my week!) is that matron, immediately told me that she had sat with her whilst she fed him a very small amount of smashed food and gave advice on safer feeding “like you told us in the training session”. The majority of work I’ve been trying to do out here is with the mind-set of training others/giving information to promote speech and language therapy and to provide some sustainable information/training that parents/carers/teachers/hospital staff can continue to use after I have left. This is a great example and am very proud as there have been many examples of people taking on specific advice and making those changes but this is an example of someone taking on general information I’ve given and applying it functionally within their setting. Matron Jane I salute you! :)

Paediatric Client J, after waiting 2 whole days for an NG Tube, according to the records put on almost 1/3 of his body weight in just 2 days (10kg up to 13kg). On leaving the ward, one of the doctor’s involved in the whole “ugly” situation from last week said to me “oh, have you seen J? He’s doing so well isn’t he”. Mentally, I  was holding  my face in my hands, shaking my head in dismay and saying to her “well, considering he was not placed on an NG tube for 2 days I think your very lucky he is still alive, let alone doing well. And you shouldn’t seem so proud about it, because you  personally did very little to help the child”. In reality, I just nodded, smiled and said yes. The next time I went in J had dropped in weight to 11kgs yet had not been vomiting according to mum. It turns out that the original readings taken by the nutritionists (another sign of how inept they are) were done wrong and J had not put on all that much weight. The good news is that he is putting on weight, slowly but surely.

Also had my last ever stammering support group which although started slow with few numbers (due to a mix-up with staff over time and the fact we don’t get too many people come anyhow), ended up being a fairly successful meet discussing future plans/handover and managing to drag in a decent number of teachers to watch a video, listen to our heartfelt pleas of how important their contribution is and to get information. Special thanks to the pictured family of Thomas and his parents who have really been at the crux of the formation and continued presence of this group. Sterling work!

Round-up:
I had to write up a report of sorts for the Education, Assessment and Resource Centre (the clinic) to show the work I’ve gotten up to since being here. I’m very proud of what I’ve managed to do and have copied/pasted some of it below as well the things I would do differently if I could go back in time (there are few!):

An estimated 30 visits across 7 different schools - These schools ranged from special schools for the “Mentally handicapped” or “Physically Disabled” to mainstream schools with special units and mainstream schools who had children with various speech, language or communication problems All of the trainings given promoted Speech and Language Therapy and were specific to observations of students and teachings within the schools. Examples being workshops on Dysphagia (swallowing difficulties), Autism, Stammering, Basic Communication Strategies and feedback from classroom observations.

An estimated 25 home visits to a total of 20 children - These home visits were reserved for those who it was felt required observation within the home environment as clinic/school visit was felt to not give an accurate portrayal of the child. The home visits were primarily for selected children with diagnoses of Autism, Learning Difficulties, and Selective Mutism, Following these visits, parents/carers were given information and advice specific to their child.

Work was carried out at 2 hospitals in the Kisumu area,The Provincial and the District Hospital:

At the provincial hospital Speech and Language Therapy services were offered alongside the Occupational Therapy (O.T) on a weekly basis. Additionally, referrals were made to Obama Children’s hospital to see specific clients on a weekly basis. Although the majority of work was with children with Cerebral Palsy (C.P) or Autism, a number of adults who had CVA’s (Stroke) were also referred for Speech and Language Therapy. Basic training concentrating on Dysphagia (swallowing difficulties) was provided on 3 separate occasions - to O.T’s and Ear, Nose and Throat staff (ENT) (12 people), mixed hospital staff (16) and Doctors and Nurses from Obama Paediatric Hospital (28).

At the District Hospital Speech and Language Therapy services were offered on a weekly basis for a period of a month across all areas of the hospital. Basic training concentrating on Dysphagia (swallowing difficulties) was provided to 37 staff members from all areas of the hospital, the majority of whom were Doctors and Nurses.

At the Education, Assessment and Resource Centre (EARC) Speech and Language Therapy services were offered on a weekly basis. Working in a Multi-Disciplinary Team alongside specialists in hearing, vision and mental health, the EARC assesses children for the primary aim of placement in a school appropriate for their needs.

Western Kenya’s first ever Stammering Support Group has been running on a monthly basis since August with an average of 10 people per meeting. It is hoped this shall continue every month with at least one speech and language therapist from Yellow House (Vihiga) joining locals who will take the lead in running the meetings.

An event set-up for International Stammering Awareness Day brought over 50 children and adults to come together to learn about Stammering (workshops and guest speakers were present) and meet others who Stammer

Western Kenya’s first ever Autism Support Group was set-up in January with 16 parents and professionals attending. It is hoped this shall continue every month with at least one speech and language therapist from Yellow House (Vihiga) joining locals who will take the lead in running the meetings.

Overall it is estimated the Speech and Language Therapy Service set-up in Kisumu has:
Informally assessed (and given advice to relevant parties) approximately 200 children
Informally assessed (and given advice to relevant parties) approximately 30 teenagers
Informally assessed (and given advice to relevant parties) approximately 20 adults


A few things off the top of my head I wish I’d done differently:

1. Allocated my time in a better fashion! I was a little here, there and everywhere in terms of work and part of me really does feel that concentrating on a smaller number of schools but being a more constant fixture in them would have resulted in a better impact overall.

2. Similarly, due to splitting my time across so many areas/settings, a lot of the trainings I did were more a case of throwing as much information at as many parties as possible and hoping that some sticks. Taking a smaller number of schools and ensuring I was there for a full day once a week for example would have allowed in-class training and actually showing teachers the things I had spoken/showed within the trainings.

3. Started work at the 2nd hospital earlier - Weird as it may sound I really enjoy working in a hospital setting and the District Hospital’s staff were very welcoming, gave me so many clients who required some support and best of all were interested in the work I was doing (“who wants to learn, come and watch the mzungu doctor!) and were very good at taking on information and carrying it out promptly when asked.

4. Just an idea I literally just had, which I’ll be passing on to Rach/David (who are still in Vihiga until June and will hopefully be coming down for a number of days each month) and Carmen who has been persuaded to move to Kisumu for 6 whole weeks woohoo! To try and have a big meeting with a load of principals and/or teachers from all the schools I’ve worked at (and more!) to try to come to a sort of agreement that at each and every stammering support group and autism support group there will be at least 1 member of staff present. This would mean that there could be a rota of sorts so it would be officially sanctioned by the principal rather than “anyone going to the thing on Saturday? Nope. O.k”, which in turn should hopefully mean greater knowledge spread of these 2 areas, greater support for all in the groups and possibly lead to more people wanting to attend :)

And that’s a wrap folks. As mentioned, when home I’ll write a little mostly non-work orientated what I’ll miss/what I learnt about Kenya kinda thing.

Saying goodbye hasn’t been too bad because mzungus out here are fairly transient in the work they do unfortunately and in most cases it’s “goodbye, thanks, when’s the next one coming out / what happens next” which is how it should be and thankfully made saying goodbyes a little easier. However, saying goodbye to the wonderful Mr.O (see previous posts) and his family almost made me turn into a blubbering wreck - they have been truly wonderful to work with and I really hope to keep in touch with them.

Really want to say a million thank-yous to everyone who has supported me through probably one of the more stressful/tough times in recent years. This includes all those wonderful people I’ve met in Kenya (particularly those I’ve been working with), all the lovely people from round the world who have read this blog, those of you who have sent me lovely cards/parcels and comments/messages from friends and family.

Love you all tonnes,

J xxx

PS: Dear all SLT's/SLP's if you haven't already please join/check out the project I'm doing to promote what we do (no-one has a clue!) whilst also providing information to the general public - it's in the beginning stages but coming along nicely :) - http://www.facebook.com/groups/196799610418947/?bookmark_t=group

Top 3 songs played on Itunes shuffle whilst writing this:
1. Evening Kitchen - Band of Horses
2. Memphis Bell - The Prodigy
3. Latchmere - The Maccabees

Why can't you do your [insert favourite expletive here] job?! and other (better) tales

It’s the good, the bad and the very ugly (see aforementioned title) part 2. There were plenty of great things that happened since I wrote here last but alas you can’t have the ups without the downs. And unfortunately there were a few absolutely soul-destroying, infuriating and “I can’t even begin to put into words what I’m feeling” moments. In fact, I think that in general I’m a fairly laid back individual and for the first time in forever I actually went a little Incredible Hulk on some people… so let‘s start with all that nonsense, an interesting thought (I think!) on death and finish on the good notes!

PS: Apologies for a lack of photos this blog - a lot of work has been in hospitals with patients who are very poorly/palliative (end of life care) so I didn’t want to/it’s not appropriate to take photos. There are a couple and a video (!) at the end though.


Ugly:

Where to start?!…

I guess the main thing that covers everything I want to rage about is the title of this blog entry - “Why can’t you do your [insert favourite expletive here] job?”. The longer I spend out here the more I see people not carrying out their job fully. Whether this be a nutritionist seemingly being absolutely clueless about nutrition or more to the point professionals only focusing/looking at what their task is with a particular client and not looking outside of that specific task.

These are the things I have done this week that although on occasion may* be part of the job remit of the speech and language therapist (we do a lot of work across many different environments and alongside many different professionals) are not in general what I should be doing. As I mentioned last week - these people have common sense and are trained in these areas, it’s not that they are not/”this is Africa”:

Advise and take a client from the Occupational Therapy Department to the in-patient ward due to severe malnourishment (Client J: 7 yr old [had a cerebral infarct last year], 10kg. The optimum weight is 23kg). I honestly think that the O.T’s would have either just done their job  (O.T work) and send the client home or just said “you should go to the nutritionist”. To which the client would almost certainly have gone home (I had to spend a good 30 minutes explaining why the child needs to go into the in-ward and she still wanted to go home first to pick things up. I pretty much refused that option as felt she wouldn’t have come back)

Getting people to do things/bringing teams together. MDT work/Communication between roles is not something that is effective here, once again possibly due to the “this is my role, I’ve done my job” mentality. These are the stages in what I had to do with the above child - expect lots of angry CAPS LOCK (this is when I went Hulk-tastic on the staff). After getting the child into the ward and explaining everything to the doctor, she did her job - case history/admittance. I asked for a nutritionist to come and talk to the mum - the doctor said she would go and get one… 10 minutes later I go looking for a nutritionist. Who is hanging around in the nutrition room. The doctor didn’t mention anything to her. I round the both of them up to come and talk to mum together and all of us as agree as one big happy family (soon to go through a nasty divorce) that the child will be fitted with and IV drip for hydration/take bloods, a NG tube for feeding and be on a special nutrition plan for 2 weeks minimum. 3 doctors tried and failed numerous times to put an IV in his hands/arms as the child was so thin. Carmen, a visiting Speech Therapist said to me possibly his foot might be better… after seeing even more failed attempts I decided to speak out and first time they tried they got it in. He was then placed in a bed, all was well and I buggered off to do other work. As mum was very worried about the whole situation I popped in early the next morning to see how things were. HE STILL HADN’T HAD AN NG TUBE PUT IN. Due to this mum has been feeding her hungry child orally which was making his chest/breathing worse. I had a bit of a go at the staff, whose explanation was that when they went to fit one the mum said she was feeding him fine. “O.K - The food is going into the child’s mouth… and where exactly does it go from there?.. Yesterday we all agreed the child needed an NG tube as he is seriously malnourished and a feeding assessment (I saw mum again that day feeding) showed he is not safe on anything oral. WHY ISN‘T HE ON AN NG TUBE?” Explained to mum, the doctors and nurses. Right. Next morning I come in AND HE STILL ISN’T ON A (INSERT EXPLETIVE OF CHOICE) NG TUBE. I pretty much lose it at this point, tell the doctor in charge of that particular unit that “I’m not leaving until an NG Tube gets placed and that’s going to happen right now”. Less than 3 minutes later the child has an NG Tube. I can’t even begin to write how I felt that day and how I feel now just thinking about it. Mind-blowing ignorance/failure of responsibility. As I was there I also got hold of a nutritionist to immediately weigh the child and explain to mum the feeding timetable. That morning any professional I bumped into I explained that a child who desperately needed a NG Tube, after everyone agreed, did not get one for 2 days. Makes me ill thinking about it to be honest.

Had to place 2 children on Nasogastric Tubes (NGT) for feeding and en. These children are very malnourished, have no safe swallow, cannot support themselves and are not alert for the majority. Why are they not already on an NGT? Doctors, Nurses, Clinical Officers, Nutritionists?

Pretty much do some of the nutritionists work as they seem massively incompetent. In fact, a visiting speech therapist made this point. I have constantly been asking for nutritionist support for a number of children to which I have always got the reply - “yes, we are giving them special milk and porridge”. The fact is, without knowing the first thing about nutrition, I know that whatever this special stuff is it is not working - Paediatric Client C (who I have mentioned umpteen times) has lost a third of his body weight in 3 months and been on an NG tube the whole time. Whether mum is not feeding him as she should (I don’t believe this) and/or the nutrition support given is not enough (I strongly believe this) it is the nutritionists job to be in charge of this. Additionally, 2 types of food is not good enough for a child. Using cheap, easily obtainably resources  I’ve just started giving my own advice regarding using juice and avocado and smooth peanut butter, mashing/mixing with yoghurt and/or milk so it flows through the tube. This will give the children umpteen amounts more good fats and put on weight quicker.

C has been on numerous drugs for all sorts of things, has constant seizures and fevers and a lot of neurological things going on. Up until a few weeks ago he was sleeping/not alert for the majority of the times I’ve seen him. I enquired that I knew he has a lot of things going on but whether the amount/type of drugs he is getting is adding to this. The matron and doctor looked through the notes and said for his weight and his difficulties it is what he needs.. O.K, I’m not a doctor so fair enough. The times I saw C last week he has been a lot more alert then previously… I asked mum if anything had changed. Yep, they’ve changed his drugs. I literally don’t know the first thing about pharmaceutical stuff/drugs but again without looking outside of the job box - the doctor’s want him to have reduced seizures and so lump him with a load of drugs that are meant to help.

I’m not sure if I’m ranting too much but I just can’t understand where this lack of responsibility/carry through takes place and feel a lot may stem from how people view their jobs/tasks perhaps.


Bad ?:

Not really much to say here, more a couple of interesting thoughts around death and the way it’s viewed here and the possible after effects on hospital care. Carmen mentioned that she thought perhaps in Kenya, death is more easily looked upon/is a more common part of life here - this was after I’d seen 3 recently deceased bodies that week and one of the clients had lost 10 of her 12 children. My retort was that I definitely think there is a “healthier attitude” towards death as some may put it by a very short mourning period for most as it for many I think its fairly common for someone you know to die on a regular basis here (I mentioned my landlady has been to a funeral on average every 2-3 weeks since I’ve been here).

One effect of this is possibly that people are less likely to want to support their child and pay medical expenses, rather accepting the fate of death than a bill and looking after a child who will be more a hindrance than help in daily life. I very much feel this was almost the case with client J (above) who spent 4 months in hospital after a cerebral infarct which cost the family a lot of money. It was her main concern and mentioned it a number of times and was seriously taking her son home rather than foot a bill.

The other possible effect, of which I witnessed a lot of this week is lack of end of life explanation/advice/options. 4 adult clients I saw this week ( 3 of which are mentioned below) have very poor prognoses and are on/expected to be on palliative care shortly. All 4 of these clients have no swallow or a very very poor swallow (very slow, very weak) to speak of and in regards to advice/options there has been none. After I informally assessed and gave advice to the clients I sought to speak to staff members concerning there condition - the fact they should not be taking anything orally but yet are not on NG Tubes. For some it’s a case of they have some mobility and on previous occasions have taken out the tube, for others there has not been any attempt to make this happen. My gut feeling is that due to the condition of these clients there may not be any point in keeping them alive - at the cost of the hospital and family’s time and/or money. I spoke to the doctors/nurses about the situations of the clients and that it is likely that all these clients will die unless they are placed on an NG tube, but if they are likely to pass away then maybe it should be discussed with family members whether to try an uncomfortable NG tube for feeding with some hope of recovery or to let them be as comfortable as possible and not prolong life. And that it would be great if possible to explain options which doesn’t seem to be happening.

Like I mentioned, I feel this may be a cultural difference and just “how it is” here but it was nice to be able to find out a little more and to discuss issues like this that my not have previously entered the minds of some of the staff at the hospitals.



The Good (at long last!):

Paediatric Clients C and J 

They seem to be getting more alert and stronger by the day which is the first real step to possible recovery. Without energy or alertness it would be incredibly difficult for them to re-learn skills due to lack of focus, attention or energy to carry out tasks.


The Parents, Wives and Husbands of those in hospital

The carers of those in hospital have been nothing less then incredible in taking on the advice I have given to them. 4 stand out cases emerge that I’ll very quickly write about:

Client L, in the female ward currently has meningitis with complications and very little awareness and understanding of language and no expressive language to speak of and therefore all discussions were directed towards her husband. The husband has very good English and seemed to understand all information I provided on safer feeding (I also written notes for the client with what I have recommended as well). The following visit, he had her propped upright in her bed and feeding her  beautifully thick, smooth, mashed amounts of banana. Unfortunately this is one of the client’s I have just mentioned and he has decided/been persuaded to not try another NG tube fitting and is essentially choosing oral feeding even though she has no swallow to speak of and is very underweight. I do not see her staying alive for much longer as things stand.

Client E, residing in the paediatric unit is the child I mentioned last week. She is on an Nasogastric Tube (NGT) and I was personally worried about her level of nutritional input as the dietary requirements for her weight, as recommended by the nutrionist, were not being met by the mother. After checking in on mum and child, it was found that E no longer had an NGT,yet was not safe to swallow and although mum had done an phenomenal job of feeding her daughter the optimum nutrition and filling in the feeding charts I had put up, they were not replicated by staff as requested. After speaking to doctors to get an NGT back in and to the nutritionist on the benefits of the feeding chart and for them to be replicated both these things were done immediately and the next time I was in mum had a beaming smile on her face and very proud of her fully filled in charts. I will also speak a little more about this client later..

Both /Adult clients C and J’s respective wives do not speak English and upon asking them “English?” “Kiswahili?” “Dholou?” it was determined that C’s wife’s first language is Dholuo and J’s wife’s is Kiswahili. Alongside an appropriate interpreter (doctor/nurse) I gave showed them and gave advice upon oral hygiene (examples, cleaning teeth/gums without water/toothpast and applying oral gel medication in the safest way possible. They both have no swallow to speak of and therefore using water/toothpaste/too much oral gel is likely to be aspirated into the lungs) and basic guidelines for safer swallowing. I also asked the MCT member to write down in the wifes’ first language the information I was giving. To be giving information about something fairly serious, whilst your respective other has a very poor prognosis, by someone speaking a language you have no understanding of must be a fairly scary situation but they were unbelievable great in listening, asking related questions and immediately as I left started to put into practice the advice I’d given :)

Clinic
Although I’ve been shifting towards hospital work for the last few weeks, I’m still rocking the clinic on a weekly basis and it’s busy as always giving me a lot of different kinds of clients, both in age and diagnosis to informally assess and give advice.

Carmen
It was lovely to have an experienced Speech and Language Therapist shadowing me for 3 days - Some lovely feedback and some great little tidbits I picked up off her were really helpful.

And that’s it..!

Off to my last ever stammering support group and then a few more days of work and I’m done! It’s gonna be a little hectic as I’m trying to leave behind a pack of info at all the schools and hospitals I’ve been plus do some reports and other stuff so although I’ll be finishing clinical work very soon I’ve still probably got a chock-a-block week of sitting in front of the computer :( !

Here's a video of a lovely bloke I met during the conference in Uganda in January who kindly let me film him speaking about stammering and allowed me to share it with the world wide web as well as the stammering group:

Apologies for poor English, punctuation and nonsensical sentences - I just type away and don’t really check over stuff! Lastly here's a couple of pics - one of "the last supper" with the clinic crew and a feedback meeting at one of the schools I work at.

Take care everyone,

J xxx

Top 3 songs played on Itunes shuffle whilst writing this:
1. Shine A Light - Wolf Parade
2. Ghost Of Corporate Future - Regina Specktor
3. Head Cut Off - The 88

The good, the bad and the very ugly (as in absolutely shocking)

Welcome welcome one and all for a bit of a long (hopefully interesting) ranty one this time round I’m afraid!… Firstly I wanna congratulate all of the 2011 City University Speech and Language Graduates! (That isn’t meant to be a self-congratulatory pat on the back) Woo-Hooo :) and now onto the good, the bad and the very ugly (and by that I mean some pretty shocking things from this week).

The Good:
Last week I carried out 2 training sessions at 2 different hospitals - the 2 biggest in Kisumu, the Provincial (“Russia” where I have been working weekly) and the District. The turn-out was great - for Obama Children’s hospital (“part of Russia”) 28 Doctor’s and Nurses came along and at the District 37 staff members (mostly Doctor’s/Nurses but others from different areas of the hospital came too). On the whole they all seemed genuinely interested in what I had to say and had far too many questions to ask about all sorts which was brilliant if a little hard to answer well at times :S

It was the first time I’d been in the District hospital and there were some great things that arose which I wasn’t expecting at all - firstly I was taken around and introduced to EVERY SINGLE ward to introduce myself and explain why I was there and the types of difficulties people may have that I can possibly support. Although some units probably are not too relevant to me e.g: Maternity/New borns, Obs/Gyn it was still great that Boaz, the O.T showing me around realised that anyone can have an impairment in the area that Speech and Language Therapists work with and felt it was important to promote who we are/what we do to all J Whilst going around I noticed signs up for the meeting I had held in practically every department! I believe this is common practice here but compared to “Russia” where it seems to be done by word of mouth it was lovely to see such good communications/promotion of CME’s (Continuous Medical Education seminars).

The last great thing was at the psychiatric ward (only one in Kisumu I believe) where I was expecting a real horror show of people strapped to beds and staff members not really doing much. The guy in charge immediately mentioned a lady whose speech becomes unintelligible when she speaks quick/gets excited (“Cluttering”) which was great and then he took me inside the unit to meet her. Walking into the unit wasn’t scary per se but it did seem very reminiscent of a prison scene - all patients in Jail-esque outfits, one open air area in the middle with a few benches around and then dorms either side. The lady didn’t particularly seem “with it”, which may be the drugs which the patients are on or just her general being and did not speak to the guy in charge very much so couldn’t really see the impairment (as such). The rest of the patients (a mix of sexes, ages between teenage and 60’s) were a little overeager to touch me/say hello and for a split second I thought it was going to kick off a bit but everything turned out alright! I’m only at this hospital for 2 more times before I leave and there are a load of people to see in the surgical unit, male and female inpatient unit and paediatric unit so I’ll just return to give the head officer some written information on cluttering. I did ask a few questions about the unit and the 2 big things that stood out to me were that family members are the ones that choose to put people in the unit via a doctor's assessment (though considering money is a big factor here I assume a lot are willingly accepted purely on the basis of what the family report) and that to be "released" they have to pass a "mental exam". I asked about whether social skills were taken into account e.g: training to go back to the community. The head said that "Unfortunately due to lack of staff and safety concerns this is just not possible" which I can understand from one point of view - resources here aren't great - but from the other point of view releasing potentially dangerous people back into the community based solely on a "mental exam" seems more of a safety concern than being one staff member short for 10 minutes a day perhaps..?

Due to some pressure from a few parents and the influential ASaLTEA conference last week, I quickly pieced together an Autism Support Group (Western Kenya’s first as far as I know!) which went much better than I expected with 13 mothers, 2 teachers and 1 nurse turning up. My aim was for 10 people to come so was dead chuffed but at the same time at least 3 parents and 3 teachers who were dead certs to come didn’t so hopefully next month’s one will be even bigger (I‘ve dragged in a few people to continue the group and will make sure David and/or Rach will be there too)! It was fairly hard to work out what to present as most of those who turned up I’ve done a basic Autism workshop with before, but the most difficult thing is the abilities of each child is sooo different that some information may not be suitable for some children and I don’t want the parents to zone out/go to sleep! I ended up going back over sensory needs (asking them to keep a diary and try to discover patterns around the times when the child calms down to use during those times of hyperactivity for example), the diet (there’s hardly any evidence!!) and showing how to make some basic AAC (Alternative and Augmentative Communication) devices such as “now and next” boards and basic picture communication boards/books. I also showed some videos of Intensive Interaction which was relevant for many of the parents. Overall, it was a success I think as the main reason for the meeting was to meet others, share information and experiences etc.. and almost an hour was spent with people introducing themselves and voicing their grievances with many of them vocally supporting the need to love your child no matter what :)

Bad:
Although over the moon with numbers who turned up for Autism Support Group, out of 16 hospital staff who were “interested” only 1 turned up and out of maybe 7 or 8 teachers/professionals who I was hoping/expecting to come only 2 did.

The more work I’m doing in hospitals, the more people there are who are seemingly beyond help - case in point being a 14 year old girl who is continuously having seizures, malnourished, on a Nasogastric Tube (NGT) for feeding as her swallow is poor and has a whole host of things going on affecting her brain (e.g: Sickle Cell, Malaria, TB) and a 72 year old man who had a right sided CVA (Cerebral vascular Accident) approximately 2 weeks ago. I’ll speak about both of them to varying degrees below, in the “ugly” section.

Oral Hygiene. That being the care of the oral area such as brushing, using medication to clear up infection and hydration. I’d always figured this was families responsibility (in fact I think I mentioned it in a past post) but low and behold when I brought it up at the training sessions they said it was the nurses responsibility. I therefore went off on a little telling off that sure it’s important for family members to be involved and know how to support this area but if it’s the nurses responsibility they should be carrying it out alongside the families or at the very least teach carers how to do so and check up on the client. None of this has ever really been done to my knowledge - definitely not with brushing of teeth etc.. and my gut feeling is any oral thrush medication is just given to the family and told how many drops/spoonfuls to give per day. A great example is the 72 year old I mentioned above - he has oral thrush and it looks like no-one has even looked in his mouth let alone brush his teeth in weeks (there are lots of bits of stuff stuck in between his teeth). On my next visit on Tuesday, I will show both the wife and staff how to apply oral medication safer (gel on gauze and dab rather than crushed pills in water) and how to clean his teeth (using water or toothpaste will create saliva and foam which the client is likely to aspirate on).


Ugly:
Client C, who I have spoken about a number of time previously  - 11 years old and has been in the ward for almost 3 months. He came in with meningioencephalitis (meningitis and inflammation of the brain) from which he has had several complications. He is on an NG tube, severely underweight, has very little movement, possibly blind, has some understanding of language but no way to communicate at the moment and does not have a safe swallow on any consistency.

The hospital tried to discharge him.

This makes me soooooo angry because not only is there NO WAY IN HELL this child should be discharged but additionally if mum is happy to be there supporting him, paying the fees etc (which is a BIG factor here) why should they try and turf him out because they “can’t do anything for him”. Firstly, there is ALWAYS something that can be done that is making his quality of life better than it would be at home (in this case he will almost certainly die if he went home) and secondly, you only have to look at client M who staff felt the same way about only a month ago and now she is doing unbelievable well. I’m not saying this will happen to C but if he goes home, the same as if M had, death is the likely consequence.


Back to the 2 patients I mentioned earlier:

Whilst reading through the notes of the 14 year old girl I noticed 2 glaring things - Firstly when she entered the hospital her age was marked as 14, then halfway through the notes suddenly she becomes 12. This doesn’t really have an affect on intervention but somehow something as simple as this has been miswritten - when I asked mum she immediately said 14 so it’s not like she doesn’t know/is unsure of date or birth which is pretty common here. Secondly, I noticed that the ideal liquid diet (through her NGT) for her weight is 2700ml according to the nutritionist. Her current feeding charts marks her as having on average 4 feeds of 300mls a day - 1200mls LESS THAN HALF WHAT SHE NEEDS. I approached the doctor’s about this who initially seemed taken aback by this fact and then proceeded to name 3 reasons this may be.

Number 1:
Doc: “You know sometimes it’s difficult for children to keep food down through the NG Tube”
Me: “She vomited twice on the first day she was in/on an NG tube, since then she has retained all feeds for the last 10 days”
Doc: “Oh”

Number 2: Families can not afford food. Understandable and fair point. I enquired with the nutritionist and basically they have NO funds to provide anything free nutrition wise (e.g: extra nutrition flour/special seed/nut paste sachets).

Number 3:
Doc: “You know sometimes mothers feed their children and don’t immediately report it to the nurses”

After chatting to mum and a few nurses who I dragged into it, I came up with a dietary timetable, exactly the same as the one in the notes which is to be stuck on the wall next to the bed so Mum can immediately mark down when she feeds. I feel it may also be good for her to have the exact amount written down and the amount of times she is meant to be feeding her child to get her to hopefully realise how underfed she is at the moment. I told Mum I realise how hard it is to feed every 3 hours all day/night and that money for food is an issue but that I was expecting the intake to be AT LEAST 6 feeds rather than her current 4. We will see on Tuesday how things are going..

The 72 year old has left-sided hemiplegic (paralysis of the left side), visual difficulties, doesn’t seem to be understanding any language and does not produce any spoken or body language to speak of according to wife/nurses. He does not have any swallow to speak of. They tried twice to put in a NGT (Nasogastric Tube - which allows feeding straight to the stomach whilst bypassing the throat and the risk of aspiration [food/drink going into the lungs]) but it failed. Why? The nurses could not tell me. So he has been fed porridge/liquids and been given crushed drugs mixed with water all whilst he has absolutely no swallow to speak of and is coughing (I.e. aspirating) anytime he is given anything orally (according to the wife). He desperately needs to be put on an NGT, which I spoke to the nurses about, who agreed with me.. AGAIN WHY ON EARTH HAVE THE STAFF ALLOWED ORAL FEEDING/MEDICATION TO CONTINUE???!! Don’t get me wrong - I realise we are in a 3rd world country and things are different to back home etc.. BUT these guys are trained doctors and nurses AND there are the facilities in place (I.e. NGT) to support this client but nothing has been done in 2 weeks or so.

Continuing on a similar vein - LACK OF KNOWLEDGE HERE IS UNBELIEVABLE (and I don‘t mean in terms of people don‘t understand or need to know more about certain areas). Some examples from training:

56 out of 69 hospital staff (vast majority of Doctors and nurses) thought cutting a tongue tie improves speech

Only around 50% could label more than 7/12 labels on a diagram of head and neck

When talking about swallowing difficulties, I asked a doctor to explain to me what aspiration was. He had no idea what the word meant. This is a word that is used here, there is no Kiswahili alternative used within the hospital and all discussions/notes are in English.

Can’t really put my feelings into words really - Sometimes things are the way they are because of lack of money, lack of general knowledge, common superstitutions/beliefs but as with feeding issues these are all things doctors and nurses are trained on. F*cking unbelievable.

Apologies for the bit of a rant today but I think it’s a fair reflection of some of the practices out here and if I don’t rant to someone than I’ll prob end up destroying some relationships I’ve built up with staff/friends out here!

Only a few more weeks left and only one and a bit of work so you only have to be bored by me a couple more times and I’m off!

J xxx

Top 3 songs played on Itunes shuffle whilst writing this:
1. FreeBird - Lynard Skynard
2. Everlong - Foo Fighters
3. Titus Andronicus- Titus Andronicus

Some pictures and a little bit of learning!

To start with , some pics from the clients I specifically mentioned last week - M and Mr Oteng and some before/after type of pictures! :)

M’s improvement, as mentioned, seemed to have nothing to do with a change in medication/care, just a good ol’ fashioned miracle - especially considering the diagnosis and her condition when I first saw her (see previous posts). I can honestly say that although I did my utmost to explain M’s eating and drinking difficulties and try to work on that aspect (again, see previous posts) , the reason why M is not only on the road to recovery but even alive is 100% down to mum. She was the one who decided not to be discharged, especially under duress by hospital staff to free up beds (f’n ridiculous if you’ll pardon my language) and did amazingly in carrying out oral care (the responsibility of the family not the medical staff out here) and following strict instructions regarding food/drink. A wonderful mother and a wonderful kid. I saw M today and she is already understanding “Wh” questions (What, Where etc..) and responding in beautiful sentences.

I would like to point out that in this picture
M is not smiling but clenching her teeth as
a result of a seizure that occured days previous.

A beautiful young girl hopefully on the road to full recovery

Mr O and his recovery is again a testament to not only his strength but also the support of his brother George. I have made a number of blog entries regarding the incredible support/work the duo have made and the steps George has taken to not only support his brother but also relay all information to other family members to carry out strategies based around word-finding difficulties, his dominant difficulty. Additionally, with the help of my Yellow House Colleague Rachael Gibson who I managed to drag down on a number of occasions to deliver oro-motor exercises, an area she is specially trained in, George and Mr O have been working tirelessly on continued home therapy in this area. I will see them for a follow-up on Friday morning to see if Mr O has done his homework ;)

Sooo - onto the main part of this week, the 4th East African Speech and Language Therapy Conference held in Kampala. As I don’t wanna bore non-SLT’s (and even SLT’s as well!) I’m gonna have a little write and then a list of ten things I learnt from the conference.

The conference was brilliant. It was the first conference I’ve ever really been to and I can confidently say it probably nothing like how a normal conference runs and even more confidently say that I hope to be back in 2 years for the next one. There were over 50 people who attended from 15 different countries - most working within or part of working wihin East African countries (lecturers, researchers, SLT’s and other professions) plus some amazing special guest speakers such as Cath Irvine (Intensive Interaction) and Lindy McAllister (Clinical Education). Rachael and Martin (O.T / Head of Mumias EARC) put on an excellent presentation of the Yellow House Team, who we are, the work we have done and the challenges we face and how we plan to overcome them. I joined them and David (O.T from Uganda who works alongside Rach) for the plenary session to answer questions. I didn't even know what the word plenary meant until the conference!

Things I learnt (among others!):

1. In 2005, the World Health Organisation (WHO) estimated 600 million people had hearing loss with 80% of cases in developing countries. The majority of these cases are preventable/treatable.

2. Currently in Kenya there is approximately one Speech therapist to every 4 million people.

3. A much nicer word for “Challenging behaviour” is “exotic behaviour” as coined by Cath Irvine (note - this is not a term that should be used in the professional world whilst writing case notes!)

4. Some traditional (still practiced) practices to eliminate a stammer are to throw a child into a river repeatedly and to eat peanuts that have been left by a parrot whilst talking.

5. Quibble seems like a fun party game

6. Research should be done into a link between SLT’s and dancing ability because on the whole people were throwing shapes on the Saturday night!

7. Intensive Interaction seems p-retty amazing.  It is aimed at children and adults who have severe learning difficulties and/or autism and who are still at an early stage of communication development however more research is coming up for other client groups it could be useful for. Check it out.

8. If interested in disability work/rights and what is happening all over the globe check out the following: “World report on disability”, “UN convention on rights of persons with Disability”, “Millenium Development Goals” and last but by no means least “Communication Therapy International.

9. Almost purely based on the conference and the speakers, many of whom talked about research, I am beginning to consider a Msc project, possibly within Kenya if at all possible. I am so easily influenced.

10. The amount of people (as mentioned) who attended, plus the types of people and guest speakers has really shown (I’ve been told by those who attended previous year/s) how much speech therapy and the understanding/awareness of communication difficulties in Eastern Africa has grown. Long may it continue.

Turns out I have less than a month left before I return! Additionalyl I’m hoping to finish up with a week spare to make sure I leave everything in a good place before heading to Nairobi a little early to have a bit of a shop and to be lucky enough to observe an experienced therapist who has been living here since 1999 :) (Thanks Emma!)

A last quick plug for a Speech and Language E-Book project I’m trying to get off the ground -  It is an E-book project whereby the aim is to create an easy to read, informative book of short stories based on Speech and Language Therapists and Service Users experiences. The idea is to promote the role of a Speech and Language Therapist, the work we do and the people we do it with. Essentially, the E-publication (through Amazon) is designed to get a greater number of people to understand what we do!

Please e-mail me if interested at jonathanmlfagan@gmail.com and/or join the facebook group cleverly entitled “SLT E-book project”

Hope all’s well with everyone wherever you may reside in the world,

Big hugs,

Jon x

Top 3 songs played on Itunes shuffle whilst writing this:

1. Small Town Girl - Good Shoes
2. To Whom It May Concern - The Civil Wars
3. Emergency - The Answering Machine

Life and Death Pt.2

I officially decided to re-start at work on January 3rd and things have been right back to usual and pretty hectic. Personally, I’m always very torn by this as I love working with both my clients as well as other members of the Multi-Disciplinary Team (all those who work with/around the client e.g: parents, teachers, hospital staff etc.) but equally part of me wishes that it wasn’t so busy and there were not nearly as many children in need.
I’m going to concentrate on 3 clients for this entry - 2 great stories of rehabilitation and the unfortunate passing away of a new client.

M is a Christmas/New Year miracle. Period.
To re-cap on the info I gave in a previous blog after I initially saw her a month ago -
M is 6 years old and has been in hospital for almost 2 months. She has had multiple cerebral infarcts (stroke) is sickle cell anaemic and is severely malnourished. The day before I saw her she had a convulsion (which are said to not be common for her) and her NG tube removed (why, I have no idea - I’ll get to that in a mo)… she is not particularly alert, has difficulties with mouth control (M has clenched teeth the majority of the time), cannot support herself at all physically and seems to have little to no understanding of spoken language…M was not safe on any liquid - not only does she have very limited movement creating difficulty to give her anything orally, she had no swallow on a small amount of water and one day I came in her mum had just given her a small spoon of very thick medicine (like a gel) which is for her oral infection - she had an incredibly delayed swallow with very gurgly, heavy breathing ( a sign things are trapped/going down the wrong way) and the majority of the medicine seeping out of her mouth over the next 10 minutes or so.

Come January the 4th and I can hardly recognise the child sat independently in front of me. I’m actually so blown away I almost immediately cry. I reach out my hand and say “habari” (how are you?) and M moves her hand towards me slowly and responds “mzuri” (fine). Not only is she independently supporting herself and beginning to move her limbs but her understanding and spoken language is coming back with mum reporting she verbally requests toilet, water, food amongst others. One of the most noticeable things about M is she has put on weight and is looking much healthier - she was taken off an NG tube when her condition was getting better and I assume they trialled feeding her and all was well and she continued to improve. Watching her eat and drink without any difficulties, a strong prompt swallow present on all textures and Mum indicating that she has none of the difficulties of which I previously explained lead me to tell a very happy mum that I could now leave them alone! I went through M’s records as well as asked mum/staff if anything was changed whilst I was away - maybe different drugs for example - NOTHING. She has literally miraculously gotten better without any change to treatment, which in essence was palliative care. I couldn’t be happier for a beautiful little girl and a very hard-working mummy.
(I should have some pics to put up next week)

Mr O is reaching for the stars
Another previous client re-cap -
Mr O is a lovely young man (32) who approximately 6 weeks ago had a stroke. He is exhibiting global aphasia (difficulties with both receptive and productive language) with very common characteristics such as word-finding difficulties (causing non-fluent speech) and some fluent unintelligible jargon-like speech. He has an unbelievable brother who is looking after him and takes notes at all meetings.

The last time I saw Mr O, at the beginning of Dec, he had come along great guns in the month or so since I first saw him and around 10 weeks since his stroke. Alongside strategies that I had provided and discussed with him and his brother Rachael came down to do some oro-motor exercise work with him to create more muscle strength and control in the right-hand side of his face which had been affected by the stroke. Before Christmas I re-did an informal assessment similar to that of my original one and he performed far better, making fewer mistakes, having more consistency within these errors - e.g: semantic errors only (using an incorrect word that is linked in meaning to the target word such as using cat instead of dog) and having clearer speech sounds. He was still using a wheelchair at this point.

Fast forward less than a month and I greet a very healthy looking Mr O sans wheelchair chewing away on a piece of gum with very little obvious difference between the two sides of his face. For the entirety of the session Mr O rarely looked towards his brother for help (which he previously did on many occasions) due to his reduced word finding difficulties. After asking both Mr O and his brother of how things are going, areas of difficulty etc.. the main area of functional difficulty seemed to lie with Mr O’s reduced ability to ask new people/strangers things. Upon discussion the crux of the matter is that Mr O is worried what people will think of him if he takes time to speak/cannot retrieve words etc. Therefore after discussing it his “homework” for the next week is to come up with a sentence that is easy for him to remember and produce accurately which explains his difficulty - an example might be “I have had an accident and need some time to speak please”. And then use this sentence with 3 people in his local community who he sees regularly but who are not friends/family - maybe shopkeepers/bus drivers etc.. I’m very interested to see whether he managed it and what the responses were!


Client M
M was a child of 3:6 with a diagnosis of Cerebral Palsy who had come into hospital a few days before I saw him (Thursday) with severe pneumonia. Before I suffered from pneumonia myself a few years back, I always associated it with chest infection due to coldness however it is an inflammatory condition of the lungs that can have a number of causes, one of which is chest infection through aspiration (food/drink going into the lungs instead of the stomach due to eating and drinking difficulties).

On first sight M was hooked up to oxygen to aid his breathing and was coughing away for the majority of the 30 minutes or so as I explained my job, swallowing difficulties and the plan (Mum had confirmed he coughs during feeding, has a chest infection and has lost weight - all signs of aspiration). I organised to come in the following morning to do a swallow assessment / observe mum’s feeding if it was feasible and safe. I trialled M on 2 teaspoons of water (the safest substance to trial on as it is ph neutral and less likely to cause infections) and he produced a delayed but strong swallow with a few small coughs afterward (a sign some may have gone down “the wrong way” into the lungs). I followed this with a small teaspoon of mashed banana to see if his oral movement/swallow was different on a different texture however there was very little oral reaction at all and I manually took out all of the banana from his mouth. Explaining to mum that he is not safe on anything at the current time it would be advisable for an NG tube to be placed with M to keep his nutrition up whilst bypassing his swallow, giving his chest a few days to heal up hopefully without anything going in. At the same time “rounds” where happening and I gave a very brief presentation to the Dr and the 15 of so students who surrounded M’s bed. Immediately after I explained all the Dr exclaimed out loud “Why isn’t this child already on an NG?” before shaking his head vigorously. Which immediately made me appreciate and think that this Dr knew what he was talking about, however whilst listening to him discuss medication options with the students TWICE I had to butt in when he prescribed “oral tablets/capsules” after I specifically said that this child was not safe on anything oral.

Just writing this is making me infuriated beyond belief as this is the SECOND time I have had to tell Dr’s to place a child on an NG tube. This was also the second time I have lost a patient out here.

I received a text message 4am on Sunday morning from M’s mother simply saying: “Hi Jonathan, your friend M has just died, L.”

My thoughts are with you little man.

I asked the hospital what the eventual cause of death was and that is still pending. I suspect it may have just been too little too late for the child due to his numerous difficulties on top of his severe pneumonia and poor breathing. However, if he had been put onto an NG tube when first admitted as he should have done would things have been different?

Almost as a direct consequence of this, I have decided to spend the majority of my last month in hospitals providing as much dysphasia training as I can, as well as working with those in need. Next week I have already booked training for the paediatric hospital staff where M passed away as well as with O.T/E.N.T/Paediatric staff at the other main hospital in Kisumu.

I’ll try not to end on a somber note - tomorrow, along with other speech therapists from Kenya, I shall be heading to Uganda for a 4-day conference - the East African Speech and Language Therapy Conference 2012. It will hopefully be a great meet where there will be guest speakers famous in the world of Speech Therapy but more importantly it will give the platform for the SLT’s in Uganda and Kenya to voice the work we are doing, difficulties we are faced with and hopefully have some good discussions about the future.

Lots of love,

Jon x

Top 3 songs played on Itunes shuffle whilst writing this:

1. The Weight - The Band
2. The Great Beyond - R.E.M
2. Suspicious Eyes - The Rakes

Christmas Catch-up

 HAPPY NEW YEAR EVERYONE!!!

As part of my extremely flexible new year’s resolutions I’m vowing to be a little more succinct and concise with my writing and as such am doing a quick holiday catch-up in the much favoured  written form of the slacker - the list!

As a pre-cursor to my next blog update I’m gonna try and get something off on Tuesday as I’m off to Uganda for the East African Speech and Language Conference 2012 (fancy sounding I know!) from Wednesday through to Monday. It’ll have some info of a proper Christmas/New Year miracle, a project I’m trying to get going and my plans for my last month here (time flies!).

Soooo here’s my last 3 weeks or so bundled into one easy package:

Highlights

1. Safari - Saw everything could’ve asked for and more! Plus camping out was lovely.

2. Wasabi - Weird eclectic reestaurant in Moshi (near Kilimanjaro) did Japanese food!

3. Feeling of sand under foot / Being submerged in water

4. Stone Town - Lovely rustic seaside town where you can lose yourself in the back alleys shopping around. Like Mombasa but nicer for my money

5. Breeze - Not commonly seen in Kisumu!

6. Stars - With no pollution across most of the locations on holiday (Safari, Zanzibar beaches) the stars were simply beautiful

7. Seafood - Makes a lovely change from the one and only fish available in Kisumu.

8. Learning to relax - I find it pretty hard to switch off and managed it a fair bit during beach time in Zanzibar. Mission success.

Lowlights

1. Long journeys being sat on my arse (24 hours on 2 buses in 36 hours for example)

2. Crazy expensive compared to Kenya

3. Hotel shower -  pretty laughable how little pressure there was and we ended up sitting on the floor underneath the tap doing some form of new fangled shower yoga

4. Vomiting; Other people - on the ferries and on the buses. Top prize goes to the elderly lady who vomited every 30 minutes or so non-stop for an entire 11 hour bus journey into a carrier bag and refused to get off the bus at the break stop to change her bag.

5. Tsetse/spider bite -  Itchy hot swollen foot for days and $80 doctor’s bill

6. Missing my family for Christmas

7. An alternative Christmas - was lovely being in the sun on a beach having BBQ etc.. but wasn’t exactly “Christmassy” for me!

I know I’ve said it a lot but a million thanks for all those who have supported me, sent me some kind words or visited my blog to read up on what I’m up to here and in general what’s happening SLT-wise in Kenya. 

Huge hugs,

Jon x

jonathanmlfagan@gmail.com

Top 3 songs played on Itunes shuffle whilst writing this:

1. Walk on the wild side - Lou Reed

2. Dragging me down - Inspiral Carpets

2. Bliss - Muse