Blog RSS https://www.vumc.org/anesthesiology/ en Kaylyn Sachse https://www.vumc.org/anesthesiology/blog/kaylyn-sachse <span class="field--node--title">Kaylyn Sachse</span> <span class="field field--name-uid field--type-entity-reference field--label-hidden"><span lang="" about="/anesthesiology/users/grewelj" typeof="schema:Person" property="schema:name" datatype="">grewelj</span></span> <span class="field field--name-created field--type-created field--label-hidden">Tue, 02/04/2020 - 17:42</span> <a href="/anesthesiology/blog-post-rss/856" class="feed-icon" title="Subscribe to Kaylyn Sachse"> RSS: <i class="fa fa-rss-square"></i> </a> <div class="text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><p><em>These blog entries are the views and opinions of the residents during and after their international experiences, and do not necessarily reflect the opinions or positions of VIA or VUMC.</em><br /> <br /> <strong>First Day</strong><br /> After a long day of flights and layovers, we arrived in Nairobi after nightfall. Since the hour drive to Kijabe is via a highway that is heavily trafficked and currently under construction, a guest house in Nairobi had been arranged for the night. In the daylight, the quaint gardens of our guest house could be better appreciated - a small oasis in the middle of a large and bustling city. Our driver from the previous evening, Elius, picked us up promptly at nine and greeted us with a friendly “Jambo!”. After a “brief” stop at a local super market, we made our way to Kijabe. The road included frequent diversions off the main highway onto unpaved roads because of construction, with brief glimpses into the lives of those living in sprawling urban neighborhoods.<br /> <br /> As we neared Kijabe, we got our first good look down into the expansive Great Rift Valley. Turning from the main highway, Elius navigated down a narrow, winding road into the heart of Kijabe. The relatively small, rural Kenyan town is home to approximately 7,000 people and sits on a ridge overlooking Mt. Longenot and the Rift Valley. November is the beginning of the rainy season and the hillside was covered with lush vegetation, trees and flowers. When we arrived at our new home for the next month, we were greeted by Hellen. She gave us an overview of the house, which included basics like turning on the stove, the switch for the hot water heater and how to refill the water filter for drinking water. Hellen had another guest to welcome and left us to unpack with the promise of returning soon. Thirty minutes later we heard a knock at the door; however, when we looked through the glass there were five large male baboons sitting on the front porch. Our confused questioning of whether baboons could possibly have knocked on the door was interrupted by another knock at the side door. It turned out that Hellen had returned to the house to find the baboons on the porch, so she went to the side door. Hellen explained that while the male baboons could be mischievous and at times aggressive, particularly toward women, she had not heard of them knocking on doors!<br /> <br /> The rest of the day consisted of a tour of the AIC Kijabe Hospital, Super Duka (aka small grocery store), market and famous Mama Chiku’s restaurant. The hospital cafeteria generously provided us with a welcome meal of traditional Kenyan food - white rice, cooked cabbage, stew and what would soon become our new favorite food - chapati!</p> <p><strong>Last Day</strong><br /> Today was our last day in theater, aka the operating room. Since my fellowship interview last spring, I have spent the last year and a half looking forward to the opportunity to come to Kenya and it is hard to believe that the four weeks have come and gone.     Despite attending simulation, lectures and speaking with previous participants - nothing fully prepares you for what it is like to experience Kijabe first hand. There are stark differences between practicing anesthesia in the United States and Kenya, the most obvious of which are the availability of equipment and medications. 1) All ventilators in the ORs are refurbished models that have long since been retired from the majority of hospitals back home. 2) There is no gas analysis for inhalational agents and therefore no way of knowing or estimating MAC during a case. 3) Over half of the vents only reliably provide volume support - so to accommodate the small lung volumes of young children, the children must either breath spontaneously or be hand ventilated. 4) All “single use” blood pressure cuffs and pulse oximeters are used countless times on many patients - only being retired after they no longer stay on with the help of extra tape. 5) Bougies and stylettes are also hot commodities, so each KRNA keeps one of each and carefully sterilizes them after each use. In terms of medications, the KRNAs are taught to use what is currently available. During the past month we not only had to become comfortable using medications we had only previously read about in text books, but we also had to learn to do without medications that we are accustomed to having. The most surprising difference in patient populations is the stoicism of the Kenyan patients. Where typical American patients appear visibly anxious and request/require sedation, the Kenyan patients are calm and reserved. For example, I saw repeated patients sit straight up in the bed for a spinal with a broken leg and never flinch or complain of pain.<br /> <br /> While these differences exist, many similarities can also be found. There is the familiar hierarchal educational team structure with students, residents and consultants across a variety of specialties. In theaters 6 and 8, orthopedic surgeons can be heard making jokes amongst themselves about their physical strength and ability to use power tools. Across the other theaters, you will see many of the same types of cases being done back home: split thickness skin grafts, endoscopies, tonsillectomies, free flaps, mastectomies, thoracotomies, even pheochromocytoma excisions. Additionally, you will also find the friendly and ongoing banter between surgery and anesthesia about who is to blame for slowing down the momentum of cases.  <br /> <br /> In such a short time, a rural hospital, thousands of miles from home has started to feel more similar than different. We have made many friends both inside and outside the hospital, and even have been given our very own Kikuyu names - Njeri, Wambui (Kat), and Wanjiru (Katie). While the three of us gave daily lectures, I think we are leaving Kenya having learned as much, if not more than we were able to teach. Kijabe has reminded us to be more efficient with our resources and shown us how to provide a safe anesthetic with the limited resources that are available. The experience has been invaluable and I highly recommend it to any future residents or fellows!</p> <p> </p> </div> <div class="field field--name-field-lockdown-auth field--type-string field--label-above"> <div class="field__item">1</div> </div> Tue, 04 Feb 2020 23:42:41 +0000 grewelj 856 at https://www.vumc.org/anesthesiology Kat Lawson https://www.vumc.org/anesthesiology/blog/kat-lawson <span class="field--node--title">Kat Lawson</span> <span class="field field--name-uid field--type-entity-reference field--label-hidden"><span lang="" about="/anesthesiology/users/grewelj" typeof="schema:Person" property="schema:name" datatype="">grewelj</span></span> <span class="field field--name-created field--type-created field--label-hidden">Tue, 02/04/2020 - 17:06</span> <a href="/anesthesiology/blog-post-rss/855" class="feed-icon" title="Subscribe to Kat Lawson"> RSS: <i class="fa fa-rss-square"></i> </a> <div class="text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><p><em>These blog entries are the views and opinions of the residents during and after their international experiences, and do not necessarily reflect the opinions or positions of VIA or VUMC.</em><br /> <br /> <strong>Week 1&amp;2</strong><br /> “Everything is going to be sawa sawa”</p> <p>After approximately two days of travel, we arrived in Kijabe and started our orientation at the AIC Kijabe hospital.  The hospital was much different than I was anticipating and really exceeded my expectations.  In the past when I have traveled for mission work, we have slept in sleeping bags on concrete floors and set up offices/clinics in vacated classrooms.  On those trips, we survived on a combination of granola bars and meals prepared by the locals.  While I knew this trip was going to be different, I left the United States without fully knowing what we were going to face upon arriving in Kenya.  It was better than I imagined.  </p> <p>The hospital has ten functioning operating/procedure rooms, separate adult and pediatric floors, an emergency department (called casualty), and multiple intensive care units, just to name a few of its assets.  They also have a Kenyan nurse anesthetist (KRNA) training program to prepare and teach students to provide anesthesia for patients in both rural and developed Kenya, using whatever resources might be available in those environments.  The program even includes simulation training with high fidelity mannikins.  What I found to be most incredible during the first couple of days was the KRNAs’ ability to take quality care of patients in this limited resource setting.  Though there were times that I noticed and educated providers about alternative ways to care for patients undergoing certain procedures, there were also times that I noticed I felt uneasy about an anesthetic plan not because it was “wrong,” but because it was different.  During the first two weeks, I have learned the value of improvisation and that the quality of the care one can provide is not always proportional to one’s access to resources.  I often found myself reflecting on what my anesthetic plan would have been in the United States and whether I really needed everything I planned to have.  </p> <p>One of the biggest differences between the common anesthesia practices in Kenya and the United States is the use of neuraxial techniques for nearly all lower extremity orthopedic procedures, and even some lower abdominal procedures.  These regional anesthetics not only allow the patient to avoid a general anesthetic, but also end up being more cost effective.  This is very important among the Kenyan population who are often paying cash for their perioperative care.  To drive this point home, on our first day in the operating room, an x-ray was ordered for a patient who was postulated to have intraabdominal free air.  After what felt like hours to our impatient selves, we learned that the radiology service could not look at the x-ray and provide a read until it was confirmed that the patient could afford the x-ray.  Cost is a seemingly much more significant factor when developing the plans of care for these patients.</p> <p>On another note, I will share a few words on the food.  First, chapati is the best!  Don’t let anyone tell you otherwise.  We recently learned that this gem of a food can be purchased in the cafeteria for 20 shillings each, and so it has become a daily necessity.  We now have daily chapati with our chai; there isn’t a better way to take chai.  Second, did I mention chapati?<br /> <br /> <strong>Weeks 3&amp;4</strong></p> <p>“10 Reasons to Love Kenya”</p> <p>1.    Chapati.  Let’s start where we left off.  It was our goal to have someone teach us to make this wonderful, tortilla-like side dish before we left, but unfortunately that dream didn’t come true.  However, we did have multiple people explain to us just how “easy” it was to make and describe their process for making this fantastic food.  We will have to put our skills to the test to see just how “easy” it is.<br /> 2.    The people.  If asked what I liked most about my month in Kenya, my answer will be the people.  John, our weekend excursion driver and new friend, said it best when he described Kenyans as friendly and easy-going and said Kenyans don’t often get agitated.  I will cherish the relationships I made with people there and hope to return one day.  Everyone was so welcoming, giving, and selfless.  <br /> 3.    The animals, specifically the Pumbas.  I have seen lions, giraffes, and zebras at the zoo, but it is not the same as when you are driving around a national park and happen upon a sleeping lion who wakes as your jeep approaches and stares you down with his golden eyes.  It was unnerving but also amazing.  My favorite animals were the warthogs, such different looking creatures who suffer from short-term memory loss and kneel when grazing.  I am so grateful for the opportunity to have been able to see Africa’s wild side.<br /> 4.    The team environment.  It hardly felt like there was a drape or barrier between any group of people.  Surgeons, nurses, staff, and anesthesia providers all sat down together to make a plan for more complicated patients.  If things were going well, it was because of the team.  If something needed to be addressed, that issue became the focus and the team was gathered to tackle the problem together.  This camaraderie contributed immensely to the quality of the patient care.<br /> 5.    The laughs.  I have never heard so many belly laughs in one operating room as when I was being taught to say open your eyes in Swahili.  My accent just wasn’t cutting it.  As I said above, the people in Kenya are generally happy and while they were definitely laughing at my difficulty pronouncing some of the words, they were also laughing with me and would stop at nothing until I pronounced the words like a Kenyan.  They want you to be a part of their community.<br /> 6.    The views.  I will miss waking up and seeing the sun coming up over the Rift Valley.  It was such an expanse of untouched land.  So beautiful.<br /> 7.    The misinterpretations.  Apparently in Kenya hotel means restaurant and pants means underwear.  You can imagine our confusion when driving by a “Five Star Hotel” that was the size of a small store and John’s confusion when hearing us talk about our outfit choices on safari.  Are you going to wear pants tomorrow?<br /> 8.    The innovation.  It’s incredible how much you can do with few resources and some ingenuity.  If your suction catheter tubing and suction catheter don’t connect, there is likely an IV cannula cover that can solve the issue.  If there aren’t medication pumps available to deliver a medication, you can titrate the medication by droplets per unit time.  These anesthesiology providers deliver quality care for patients with a creative flair.  It was fun to watch and learn some of their tricks.<br /> 9.    The red dirt.  It gets on everything.  At first you are annoyed and try to scrub it off of your shoes, your clothes, the floor…the list is endless.  However, by the end you realize that it is part of being in Kenya and you go on bike rides to be covered in it.  As you board the plane to leave you realize that you will miss it and that clean will have a whole new meaning.  <br /> 10.    Chaptai.  Just to bring this full circle.</p> </div> <div class="field field--name-field-lockdown-auth field--type-string field--label-above"> <div class="field__item">1</div> </div> Tue, 04 Feb 2020 23:06:48 +0000 grewelj 855 at https://www.vumc.org/anesthesiology Tate Wolfe https://www.vumc.org/anesthesiology/blog/tate-wolfe <span class="field--node--title">Tate Wolfe</span> <span class="field field--name-uid field--type-entity-reference field--label-hidden"><span lang="" about="/anesthesiology/users/grewelj" typeof="schema:Person" property="schema:name" datatype="">grewelj</span></span> <span class="field field--name-created field--type-created field--label-hidden">Tue, 02/04/2020 - 16:53</span> <a href="/anesthesiology/blog-post-rss/854" class="feed-icon" title="Subscribe to Tate Wolfe"> RSS: <i class="fa fa-rss-square"></i> </a> <div class="text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><p><em>These blog entries are the views and opinions of the residents during and after their international experiences, and do not necessarily reflect the opinions or positions of VIA or VUMC.</em><br /> <br /> I had arrived to Kenya a week ahead of time to visit the Masai Mara with my husband, Ian, and while that had helped me adjust to the time change and to get my bearings of the geography, there was still so much to learn. While in the Masai Mara, I found myself really looking forward to getting back to work in the hospital - in a place with a new language and new customs, getting into an operating room suddenly felt like a comfort blanket. At this point in my training, performing anesthesia feels like an inherent part of me, and something that helps me feel grounded in purpose.</p> <p>While everything feels so different in Kijabe, I still find comfort in knowing my skill set and being able to take care of patients, even if the majority of them don’t speak English and I depend on our students, nurses and Kenyan nurse anesthetists (KRNAs) to translate. It took a couple days to recognize the familiar patterns - bring the patient to the operating room, attach the monitors, connect IV fluids and tubing - not because they are so wildly different but because I have become so accustomed in three and a half years of residency to how things are at Vanderbilt that any deviation from the exact supplies I have held in my hands multiple times a day for years feels monumental.</p> <p>Once I began to see the familiar patterns, what was truly unfamiliar became more clear to me. In my practice, I never expect to be lacking anything I need; in fact, if at Vanderbilt I turn around and can’t find a medication or supply that I need, I scold myself for being so unprepared. In this environment in Kijabe, the opposite is true - sometimes we feel lucky for having the right size blood pressure cuff and a pulse ox monitor that works the first time you connect it. I find myself trusting my gut more than I ever have before, because the monitors are never quite as reliable as you want them to be. If I have done everything to the best of my ability and I know in my gut that my patient is safe, I sometimes have to trust my gut over a faulty monitor. It’s almost a leap of faith to believe in myself to that extent, but as rewarding as it is sometimes unnerving.</p> <p>My biggest education in just a few days has been learning to take nothing for granted. A patient with low blood oxygen saturation triggers in my mind a long list of possible diagnoses, but equipment failure is naturally pretty low on my list. That turned out to be a mistake, because after several days and several tense clinical scenarios, we all realized that the hospital’s oxygen processing plant had been malfunctioning and instead of delivering our patients 100% medical oxygen, it was only about 31% oxygen. This isn’t always a big deal, as normal room air is 21% oxygen, but it matters substantially in children who don’t recover from hypoxemia as quickly or as easily as adults do. The solution to this problem isn’t simple, either: turns out it will be several weeks before the replacement part will be available, and we are forced to work off of oxygen tanks and conserve as much as we possibly can without putting our patients at risk. At Vanderbilt, I imagine this problem would cause surgeries to be cancelled to avoid any risk at all to patients, but in Kijabe, not performing some surgeries for patients who have saved up and traveled very far to receive care may present even more risk than working with a limited oxygen supply.</p> <p>My second biggest learning task has been to supervise people of vastly different skill sets who trained in a system far different than what I know. This week, I have been pushed harder than ever to be able to walk into a room and quickly assess what’s going on and how I can help. I suddenly have an even greater appreciation for all of my attending physicians who guided me through my early days of providing anesthesia - how often did they walk into my OR and be surprised by what they saw, only to redirect my work in the correct direction? This is made even more challenging by cultural differences, the occasional language barrier challenge, and most of all by my complete unfamiliarity to my surroundings. I don’t often have the option of fixing a problem myself, because I have no idea where the supplies we need are. I’m forced to communicate what we need to others and place trust in them to help out. For someone like myself who takes pride in being self-sufficient, it is a lesson in knowledge, trust, flexibility, and confidence all at the same time.</p> <p>I have no idea what awaits us in Week 2, but my own goal is to continue to push myself to take on more responsibility and communicate better with our learners. If I find myself in a place of comfort at the end of 4 weeks, I will be incredibly proud of what an achievement that is. Onward!</p> <p> </p> </div> <div class="field field--name-field-lockdown-auth field--type-string field--label-above"> <div class="field__item">1</div> </div> Tue, 04 Feb 2020 22:53:24 +0000 grewelj 854 at https://www.vumc.org/anesthesiology Bethany Morris https://www.vumc.org/anesthesiology/blog/bethany-morris <span class="field--node--title">Bethany Morris</span> <span class="field field--name-uid field--type-entity-reference field--label-hidden"><span lang="" about="/anesthesiology/users/grewelj" typeof="schema:Person" property="schema:name" datatype="">grewelj</span></span> <span class="field field--name-created field--type-created field--label-hidden">Tue, 02/04/2020 - 16:40</span> <a href="/anesthesiology/blog-post-rss/853" class="feed-icon" title="Subscribe to Bethany Morris"> RSS: <i class="fa fa-rss-square"></i> </a> <div class="text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><p><em>These blog entries are the views and opinions of the residents during and after their international experiences, and do not necessarily reflect the opinions or positions of VIA or VUMC.</em><br /> <br /> <strong>Blog 1</strong><br /> I consider myself reasonably well-traveled, or at least used to living for short periods of time outside of the US, as I studied abroad in Paris and Argentina in college. I wasn’t sure what to expect heading to Africa, and I was a bit nervous because I’ve had little exposure to the language, culture and history compared to the preparation that I had in college for my respective study abroad programs. But I decided to approach this trip in a similar fashion to how I had my other trips – with an open mind and a receptive attitude. I love learning, especially languages and to a certain extent, I’ve missed that opportunity since entering the medical field. I wasn’t sure what to expect, so I decided it was best to have no expectations and let the rotation unfold organically.</p> <p>The travel to Kenya was exhausting but thankfully uneventful. The landscape is beautiful. The weather reminds me of Colorado – dry and with lots of sunshine (despite it being more rainy than usual recently). Plus, we’re at altitude! Even higher than my hometown at 6,000 feet elevation. I’m huffing and puffing to get to work everyday, but as I get acclimated, hopefully that improves. It’s nice to start and end the day with a walk, which is actually what I do the majority of the time in Nashville. So, that was one lifestyle change that wasn’t very different from home, and helped me to feel settled.</p> <p>Everyone was nice and welcoming the first day and week – it has been a very pleasant start to the rotation. I have a lot to learn from them and look forward to the knowledge and skill exchange. It’s also very interesting to learn about how different health systems work and how they each have their own challenges. Some of the practices of reusing, or at least being judicious with equipment, drugs and fluids, have had an impact on me and how I reflect on my own practice. I know that when I return to the States, I’m going to try to cut down on redundant use of syringes, needles, etc.</p> <p>It has been interesting to learn how they deal with blood transfusions. For elective cases, they have family members donate blood and then type and cross it. If that blood is not used, then it goes into the general pool so it's available for trauma patients. Further, in the event of a trauma, the hospital has a list of people that regularly donate blood. So, if multiple trauma patients present to the hospital, need blood and there isn’t enough available, then the hospital uses that phone tree to call in the regular donors. Having that kind of system in place is a testament to the type of community of Kijabe: they are readily available and willing to help each other.</p> <p>The first part of the rotation has been an amazing experience thus far, and I look forward to the rest of it!<br /> <br /> <strong>Blog 2</strong><br /> Two of my goals for this rotation were to work on my clinical skills and be able to learn how to practice anesthesia without “everything” (most pieces of equipment I could want) available at my fingertips.</p> <p>I participated in a case where a child had a buccal AVM, and his right cheek was about the size of his head. He was undergoing alcohol ablation via direct injection into the collateral vasculature. But his oral opening was normal, neck range of motion was normal and it didn’t look like it would actually impair visualization of cords once the laryngoscope blade was in the mouth. We down-sized the endotracheal tube and chose a Miller blade, but otherwise our back-up plan was a bougie. A glidescope and fiberoptic are available, but we did not call for them to be in the room. And the induction and intubation went very smoothly. And it was accomplished with standard anesthesia equipment. Fortunately! It was a case I had not provided the anesthesia for back home, and speaking with the plastic surgeon, those types of cases usually go into the IR suite.</p> <p>I am also getting pulled into the endoscopy suite a lot this past week. The workings of that room are flexible; no anesthetist is assigned (but a student is), so whenever someone is free, they go into the endoscopy suite and direct the KRNA student. I was asked to evaluate an elderly gentleman with an abdominal mass, for which he needed a biopsy. I got consulted because of a history of CHF and a cardiac murmur heard on auscultation. It is unknown why he has CHF listed on his problem list and the murmur also hasn’t been documented in the chart. So I auscultate his chest, he has a holosystolic murmur heard at RUSB with mild radiation to the carotids (probably aortic stenosis) but the murmur was loudest at the apex radiating to the axilla...so then that made me think mitral regurgitation. I didn’t see any JVD but his PMI was impressive to palpate. Maybe there was evidence of left atrial enlargement on telemetry but that is tricky to diagnose without an EKG. He did have occasional PACs. He’d had a colonoscopy in November 2019, but the circumstances surrounding that procedure and anesthetic were unknown. He wasn’t symptomatic. He hadn’t ever been told he had a valvular problem. I asked the student anesthetist how they were going to take the biopsy and she didn’t know. I discussed the case, its approach and my concerns about the patient with the proceduralist and we proceeded with the case under local anesthesia without sedation. He tolerated the procedure very well. In terms of clinical exam skills, I realize that I hadn’t palpated for a PMI since perhaps intern year. This rotation is really forcing me to rely more on my clinical skills – which is great! This particular case was valuable from the standpoint of having the opportunity to evaluate a complex patient like that from scratch (usually by the time they’re presenting to surgery at Vanderbilt, they have been thoroughly worked-up), and the importance of good communication with the proceduralist or surgeon. I’m unsure of this patient’s future treatment course, presumably chemotherapy, but if he presents for surgical resection, he most definitely will require a cardiac work-up.</p> <p><img alt="morris" data-entity-type="" data-entity-uuid="" height="748" src="https://www.vumc.org/anesthesiology/sites/default/files/Bethany_Morris.jpeg" width="1122" /></p> <p> </p> <p> </p> </div> <div class="field field--name-field-lockdown-auth field--type-string field--label-above"> <div class="field__item">1</div> </div> Tue, 04 Feb 2020 22:40:14 +0000 grewelj 853 at https://www.vumc.org/anesthesiology Jaclyn Irwin https://www.vumc.org/anesthesiology/blog/jaclyn-irwin <span class="field--node--title">Jaclyn Irwin</span> <span class="field field--name-uid field--type-entity-reference field--label-hidden"><span lang="" about="/anesthesiology/users/grewelj" typeof="schema:Person" property="schema:name" datatype="">grewelj</span></span> <span class="field field--name-created field--type-created field--label-hidden">Tue, 02/04/2020 - 16:30</span> <a href="/anesthesiology/blog-post-rss/852" class="feed-icon" title="Subscribe to Jaclyn Irwin"> RSS: <i class="fa fa-rss-square"></i> </a> <div class="text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><p><em>These blog entries are the views and opinions of the residents during and after their international experiences, and do not necessarily reflect the opinions or positions of VIA or VUMC.</em><br /> <br /> <strong>Blog 1</strong><br /> Looking back on the week, it feels like we’ve been in the ORs at Kijabe Hospital for more than just four days. We arrived in Kijabe on Monday after a smooth travel experience from Nashville and a quick overnight stay in Nairobi. Monday afternoon was spent acclimating to our new surroundings and getting a tour of the hospital and local markets. On Tuesday we started in the ORs, each being assigned to a room so that we could learn about the resources we have available to us here and how to use the ventilators and other equipment that is different than what we have in the States. Since I’m in my pediatric fellowship year, I chose to work in the pediatric OR for the first week. I think I expected the OR to run a lot differently over here compared to the States but the anesthesia is rather similar so adapting to the system wasn’t as hard as I initially thought it would be. One of the major differences is the role that I’m playing is more of a supervisor/attending role than that of the “hands on” person. There are beginning and advanced KRNA students assigned to the room with a KRNA teaching and overseeing them. It can be difficult to know when to step back and give the students more autonomy and when I feel that I need to step in. I am enjoying teaching and find the students are very engaged in learning and want to increase their knowledge and skills.</p> <p>So far, I have been learning to rely more on my clinical assessment skills than on the monitors that I may or may not trust to give me the correct data at any given moment. One example of this is that while we have ETCO2 measurements, a couple days this week it was giving very low readings for otherwise stable patients. Since I was unable to come up for a reason why it was reading low on multiple patients, I had to accept that my clinical assessment of the patient was probably more reliable. We also discovered a problem with the oxygen supply during the week. Instead of giving close to 100% oxygen, we were delivering more like 30%. This explained why most of our patients seemed to desat rather quickly after induction and during intubation attempts. Also, I never could get any of the patients to sat 100% on the monitor, they all hovered between 95-97%. If I had been giving 100% oxygen (which what is assumed based on the fact that there is no air supply line) then I would have expected to be able to have an SpO2 reading of 100% on all the healthy kids. Dr. Newton and a KRNA were able to figure out the issue, but not knowing anything about the infrastructure of the hospital and how the oxygen is supplied, I would not have known there was an issue, other than my intuition telling me that something wasn’t right. They were able to install large oxygen tanks in some of the ORs so cases were able to continue as usual on Friday, however, we may be running on oxygen tanks for the next several weeks until the correct parts can be found.</p> <p>We ended the week by taking an overnight trip to Lake Naivasha. Other than a couple monkeys and birds that I’ve seen around Kijabe, this was the first experience while I’ve been in Kenya to see a lot of animals in their natural habitats. We were able to take a boat ride on the lake and see hippos, zebra, and a lot of species of birds. The hotel we stayed at had cottages overlooking the grounds and we were able to watch zebra, giraffe, waterbuck, and at night hippos, grazing in front of our room. It was nice to get away and explore new scenery as well as get some needed down time and recharge for the weeks ahead.<br /> <br /> <strong>Blog 2</strong><br /> I can’t believe our time at Kijabe Hospital is almost over. I can understand why it’s suggested that we stay here for four weeks since there is a bit of an adjustment period. I’ve been mainly helping in the pediatric OR but also occasionally supervising in a C-section room, helping resuscitate babies after C-sections, doing blocks, and teaching the KRNA students.</p> <p>Every day seems like a new challenge with the equipment. One case your SpO2 monitor is working fine, then next you can’t get it to work at all and the portable one they can find might work or might not. However, since the patient is ventilating with adequate minute ventilation and doesn’t look blue, you go on with patient care until a suitable replacement monitor can be found. Having end-tidal CO2 is very important in monitoring patients ventilatory status, however, it seems to run low on certain monitors or not work at all. I’ve taken for granted that in the US, we routinely change out the circuits and sample lines with each patient, and have spare D-fends (equipment important for measuring ETCO2). That’s not possible here due to the very limited resources, and sometimes it can take a while to find a replacement. Instead of stopping the case, we carry on, routinely checking for breath sounds, the patient’s color, and pulse to make sure we are adequately ventilating, and send someone to try to find a replacement. I’ve found that it can be hard to explain to the students why or why not to trust a certain measurement, since I’m basing it off of clinical experience and not “what the books say” should be normal.</p> <p>I’ve also had some challenging situations in the OR and in Recovery. Last week we had to emergently re-intubate a patient due to airway obstruction from their tongue swelling. It can be a hard decision whether to re-intubate or wait and see if the situation improves since there may not be available ventilators. We had tried nebulized epinephrine for stridor, salbutamol for wheezing, and kept the patient on 100% O2 by facemask but after an hour of the child struggling to breath and maintain oxygen saturations, we decided he needed to be reintubated. The only OR free at the time had a ventilator that was out of commission so we masked with an ambu bag. While it took several attempts to intubate due to the tongue edema, we were successful and thankfully did not need to do an emergent tracheotomy. There have also been several very small and very young patients that after talking with the surgeons about the anesthetic options, have been able to be done with minimal or no anesthetic which might not be considered in the US.</p> <p>I have definitely enjoyed the challenges of providing anesthesia to patients in this setting and think that I will try to continue working abroad in the future. I’ve also liked learning about the customs and cultures of the people we are working with and exploring the natural beauty of Kenya. We’ve been able to visit Lake Naivasha, the Masai Mara and Lake Nakuru on the weekends which have been great to see as well as have some time to relax. I’m looking forward to the last week at Kijabe but it will hard to say goodbye to the new friends I’ve made in the ORs.</p> <p><img alt="irwin" data-entity-type="" data-entity-uuid="" height="766" src="https://www.vumc.org/anesthesiology/sites/default/files/Jaclyn_Irwin.jpeg" width="1150" /></p> </div> <div class="field field--name-field-lockdown-auth field--type-string field--label-above"> <div class="field__item">1</div> </div> Tue, 04 Feb 2020 22:30:27 +0000 grewelj 852 at https://www.vumc.org/anesthesiology Jake Trahan https://www.vumc.org/anesthesiology/blog/jake-trahan <span class="field--node--title">Jake Trahan</span> <span class="field field--name-uid field--type-entity-reference field--label-hidden"><span lang="" about="/anesthesiology/users/grewelj" typeof="schema:Person" property="schema:name" datatype="">grewelj</span></span> <span class="field field--name-created field--type-created field--label-hidden">Fri, 06/21/2019 - 11:47</span> <a href="/anesthesiology/blog-post-rss/63" class="feed-icon" title="Subscribe to Jake Trahan"> RSS: <i class="fa fa-rss-square"></i> </a> <div class="text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><p><em>These blog entries are the views and opinions of the residents during and after their international experiences, and do not necessarily reflect the opinions or positions of VIA or VUMC.</em></p> <p>Day 11 of 27 days in Kenya. It feels a lot longer, having left my wife and 10-month-old daughter for the first time. But I am one of the visiting consultants who will spend the least amount of time in Kijabe. In the past 11 days, I have met physicians from all walks of life who have left the luxuries of the U.S. behind to live and practice in Kijabe full-time. My initial thoughts focused on what they must have sacrificed to be here, but it didn’t take long to realize how much they are actually gaining from this experience. After speaking with many of the native Kenyans, it is evident how much respect and admiration they have for the consultants who devote their time and energy to bettering healthcare in Kenya.<br /> Reflecting on our first day in “theatre” brings about a whirlwind of emotions. After spending the beginning of the day being in orientation, touring the nine operating rooms and being introduced to the KRNAs and students, David (Roberts) and I immediately started spending time in patient rooms helping with inductions, wake-ups, etc. That time was more devoted to educating us on the machines, drugs, equipment, and lack thereof than it was to us educating other anesthesia providers. Their resourcefulness and economical practices allow them to care for more patients before running out of supplies.</p> <p> As we were walking through the hall discussing our experiences, David and I were directed to OR 6 by a surgery resident who said people just went rushing in. As we entered the room, chest compressions had already begun, and one round of epinephrine was already administered. The young lady was undergoing an operation to repair a femur fracture she sustained in an automobile accident about one week ago. ROSC was achieved, but she required an epinephrine infusion to maintain an adequate blood pressure. The surgeon quickly closed the wound, and we started to prepare for ICU transport. That was when we were informed that all four adult ICU ventilators were in use, and the ICU did not foresee the ventilators becoming available anytime soon. This situation was certainly new to me. The patient needed more intense management and monitoring than we could provide. We continued to do what we could by providing hemodynamic support to the best of our ability. She remained in the OR all day.</p> <p>Around 3pm, we were called into her room to assist in obtaining further IV access. One of her lines infiltrated which meant we had to depend on an external jugular line. We were attempting to find further IV access when we saw rhythm abnormalities on her ECG monitor. Based on what happened so far, we anticipated another code event and quickly called for help and administered CPR when necessary. After nearly 30 minutes of attempting to obtain ROSC, she was pronounced dead. I have been fortunate throughout my training to not have many patients with cardiac arrests, but this situation made me realize how well I was trained to manage these situations. While I certainly wish the outcome was different, I am thankful for the learning opportunity so I can better care for my future patients.</p> </div> <div class="field field--name-field-lockdown-auth field--type-string field--label-above"> <div class="field__item">1</div> </div> Fri, 21 Jun 2019 16:47:58 +0000 grewelj 63 at https://www.vumc.org/anesthesiology Marian Murphy https://www.vumc.org/anesthesiology/blog/marian-murphy <span class="field--node--title">Marian Murphy</span> <span class="field field--name-uid field--type-entity-reference field--label-hidden"><span lang="" about="/anesthesiology/users/grewelj" typeof="schema:Person" property="schema:name" datatype="">grewelj</span></span> <span class="field field--name-created field--type-created field--label-hidden">Mon, 06/17/2019 - 12:58</span> <a href="/anesthesiology/blog-post-rss/753" class="feed-icon" title="Subscribe to Marian Murphy"> RSS: <i class="fa fa-rss-square"></i> </a> <div class="text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><p><em>These blog entries are the views and opinions of the residents during and after their international experiences, and do not necessarily reflect the opinions or positions of VIA or VUMC.</em><br /> <br /> <strong>Week 1</strong><br /> I arrived at the Kijabe hospital campus on a chilly Sunday afternoon. Helen from the housing department came to greet me and showed me to my dormitory, which will be my home over the next three weeks. She gave me a short tour of the hospital and cafeteria, then handed me the keys to my room and wished me luck.<br /> <br /> Later that day, I met up with another Vanderbilt fellow, Eugene, who had already arrived and had been working at Kijabe hospital for a week. We walked around the campus grounds and made a short trip to one of the small shops for some food items. On my return the dorm, I met some of my roommates: Kat, an American medical student at Kijabe hospital for early clinical experience and a research project; Jennifer, a pastor in training who will be at Kijabe for a six month rotation; and Amy, a native Kenyan in her first year at Kijabe for training in Family Medicine. So far, we have all gotten along well.<br /> <br /> I was a little nervous my first day in the ORs at Kijabe hospital. Thankfully, Eugene was a familiar face in the morning and helped introduce me to some of the KRNAs and a pediatric anesthesiology fellow from Uganda namedFrances. I hung around OR 5, which is typically designated the pediatric OR, and assisted in inductions, intubations, and emergences of the pediatric general surgery cases. I worked with Teddy, one of the newly graduated KRNAs, who told me he had an interest in pediatric anesthesia and we talked a little about extubation criteria in infants and children. <br /> <br /> Later Monday evening, Eugene and I went to the Dessert Night, where we were able to meet some more folks from all over who had come to Kijabe hospital. Tom was a UK medical student in his fourth year doing a couple of elective rotations in casualty and surgery; Josh is an ENT surgeon who arrived at Kijabe a month ago, and will be here for two years. I was fortunate to meet many other great people that night. I met a palliative care physician from Wisconsin, a pathologist from Texas, an orthopedic surgeon from South Carolina, and a general surgeon from Texas. It was great to meet so many people who are helping to contribute to the training of Kenyan physicians, surgeons, and nurses.<br /> <br /> Tuesday was a bit of an exciting day in the pediatric ENT room. I found myself working with Josh, whom I had just met at Dessert Night. Unfortunately, I had to delay his first case as the patient had sickle cell disease, a hemoglobin of 8, no IV fluids - so likely dehydrated - and an SpO2 of 93 percent on room air. I wanted to make sure that we had blood available in case of bleeding (he was having a T&amp;A) or a sickle cell crisis due to stress from surgery or hypoxemia. So we decided to proceed with the second scheduled case first which was a healthy two-year-old female presenting for T&amp;A due to OSA. Her mother reported a mild cough, but said she had a chest x-ray at an outside hospital, which she said was clear. Upon evaluation of her lung fields, her breath sounds were clear and her heart was RRR. Her surgery was relatively uneventful, however, she did produce copious secretions during emergence, requiring suctioning of her oropharynx and down the ETT. <br /> <br /> After meeting extubation criteria we took her to the PACU where she began to display signs of emergence delirium and was trashing around in the gurney. Afraid that she may hurt herself, the KRNA student and I decided to give her a dose of Ketamine (dexmetatomidine is not available due to price). Once the child calmed, we began to place monitors, however, I noticed that the child was no longer breathing. I tried to stimulate the patient but still no response. I quickly began chest compressions and told the KRNA student to get an AMBU bag and call for help. Once help and the ambubag arrived I began giving rescue breaths and one of the KRNAs took over chest compressions and pulse checking. My assumption was that the patient had laryngospasm and when I took a look with the laryngoscope as the nurses were drawing up succinylcholine, I was correct. Her vocal cords where completely shut and I could not pass the ETT.  We gave a dose of succinylcholine and I was then able to take another look and successfully place the ETT.  We had ROSC shortly after starting chest compressions and we were able to extubate her about an hour after initiation of the code in the PACU. It was my first time running a real-life pediatric code and though it was extremely terrifying, I was proud of myself for reacting quickly, maintaining my composure and, of course, successfully resuscitating the child. <br /> <br /> Later that same day, our sickle cell patient was brought back to the OR for his T&amp;A after adequate fluid resuscitation and blood availability. The surgeon had some significant bleeding intraoperatively, and his post-op hemoglobin was 6.7 g/dL. He was transfused in the PACU and tolerated it well. At the end of the day, I was happy with my clinical decision-making and that all my patients made it out of the PACU alive!<br /> <br /> Wednesday, I was able to work in the neurosurgery room where we started the day with a myelomeningocele in a three day old, who had delayed emergence likely secondary to hypothermia despite our best efforts to keep him warm. Then followed with four pediatric VP shunts for hydrocephalus. I could not believe my eyes the head size of these children.  I have never seen a hydrocephalus in the USA like the ones I saw at Kijabe. Our final patient’s head was so large, that I had to step in to intubate as the positioning was so challenging, it was making visualization of the larynx and glottis difficult for the KRNA student. <br /> <br /> Speaking of difficult intubations, I was asked to go to OR 3 to assist with a potential difficult airway. When I arrived, I saw a man whose lower jaw had been removed due to tumor, and needed a follow-up surgery as the metal bar that had been placed after his initial surgery became dislodged and need to be removed and replaced. I felt that this patient would likely not be a straightforward direct laryngoscopy intubation, so I opted for an awake-sedated intubation. We anesthetized his glossopharyngeal and superior laryngeal nerves with atomized lidocaine, and I performed a trans-tracheal block of the recurrent laryngeal nerve with 3 mL of 2 percent lidocaine. He was given IV glycopyrrolate prior to anesthetizing the airway, then 50mg of ketamine for sedation after adequate topicalization. One of the KRNAs wanted to take a look with DL first to assess the difficulty of the airway. The patient tolerated the DL well, however, the KRNA was unable to appreciate any recognizable structures. I stepped in with the video laryngoscope and was able to achieve a grade 1 view of the airway, and he was successfully intubated. The patient tolerated the intubation well and the ETT was secured with suture by the ENT surgery team. He was later extubated fully awake and had an uneventful recovery in PACU.<br /> <br /> After work, I headed home to my dorm and began packing for our trip to Mombasa for the 7th Annual KRNA Education Conference. <br /> <br /> Dr. Newton, Eugene, and I arrived in Mombasa on Thursday morning and made our way to the Severin Sea Lodge, where the conference was being hosted. It was a fantastic experience to meet so many of the KRNAs that had been trained at Kijabe and to learn where they were working now and what kind of resources they have available to them. There were over 100 nurse anesthetists at the conference with three East African countries represented: Kenya, Ethiopia, and South Sudan. I gave two pediatric anesthesia lectures, one on perioperative management of bowel obstruction and the second on transfusion therapy, as well as a workshop on EKGs. It was such a wonderful opportunity and I am so thankful that I was able to be a part of the continuing education of nurse anesthetists in Africa. <br /> <br /> We arrived back in Kijabe Saturday night and Eugene and I made plans to hike Mount Longonot Sunday morning.  One of Eugene’s roommates, an orthopedic resident from South Sudan joined us for the 13.5 km trek up and around the rim of the volcano.  The area was so green and lush and we were even able to see some zebra and antelope off in the distance. Unfortunately, visibility was pretty low due to fog so we were not able to see the entire crater floor. It was a difficult hike to the summit at times due to steep sections of the rim, but we endured the elevation gain and had some pretty amazing views of the valley below. <br /> <br /> Now it is time for me to wrap-up my first week and prepare for my second one here at Kijabe. <br /> <br /> <strong>Week 2</strong><br /> This was an intense week both physically and mentally. Physically tough in terms of the amount of hours worked. I spent a majority of the days in the operating rooms, often staying past 6 pm to help place an epidural or nerve block, wake up a small infant, or deal with crises in the recovery unit. It was mentally difficult in that I experienced my first intraoperative death. </p> <p>My years of being a student athlete at the collegiate level and my time in medical training have prepared me well to deal with long work hours or a physically demanding schedule. Though it is not always easy, it is something that I have grown accustomed to.  Although I have dealt with adversity and failure in sports, life, and medicine, it has never been at the expense of a patient’s life in the operating room. I have witnessed patients dying in the ICU and have been a part of code situations on the floor in which the patient did not survive. However, this was different. </p> <p>This patient was in septic shock and dying in front of our eyes. She had altered mental status, her pulse was thready at best, we could not get a blood pressure or pulse oximeter reading, and her extremities were ice cold. After she coded the first time with us, we began running a high dose epinephrine drip just to maintain a carotid pulse. By the end of the surgery, she was on high dose epinephrine and norepinephrine infusions, and had received multiple code doses of epinephrine along with large calcium and sodium bicarbonate boluses. When we removed the protective tape from her eyes, we noticed her pupils were fixed and dilated, she was not making any respiratory effort despite no anesthesia, and she continued to go into abnormal heart rhythms (junctional, bundle branch block, bradycardia).  The decision was made to discontinue resuscitation measures and turn off the ventilator.</p> <p>One of the things that I love about anesthesia is that you can devote so much of your time and attention to a single patient. You are trusted to take care of that patient and keep them safe. But sometimes, despite our best efforts, the outcome is not what we had hoped for. When an adverse event occurs to one of my patients, I like to reflect on the situation to see if there was something that I could have done differently to prevent or treat it, so I can learn for the future. After going through this reflective process with the people involved in this case, as well as with Dr. Newton who was not, I do not think there was anything that we could have done differently that day that would have changed this patient’s outcome. I say this not to make myself feel better, but because I truly believe we did our best with the resources we had available and the condition the patient was in prior to arrival.</p> <p>Though this was a demanding and exhausting week, I am grateful for the experiences and lessons I have learned.  </p> </div> <div class="field field--name-field-lockdown-auth field--type-string field--label-above"> <div class="field__item">1</div> </div> Mon, 17 Jun 2019 17:58:22 +0000 grewelj 753 at https://www.vumc.org/anesthesiology Eugene Leytin https://www.vumc.org/anesthesiology/blog/eugene-leytin <span class="field--node--title">Eugene Leytin</span> <span class="field field--name-uid field--type-entity-reference field--label-hidden"><span lang="" about="/anesthesiology/users/grewelj" typeof="schema:Person" property="schema:name" datatype="">grewelj</span></span> <span class="field field--name-created field--type-created field--label-hidden">Thu, 06/13/2019 - 13:00</span> <a href="/anesthesiology/blog-post-rss/754" class="feed-icon" title="Subscribe to Eugene Leytin"> RSS: <i class="fa fa-rss-square"></i> </a> <div class="text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><p><em>These blog entries are the views and opinions of the residents during and after their international experiences, and do not necessarily reflect the opinions or positions of VIA or VUMC.</em><br /> <br /> The flights to Kenya were easy. The legroom was sufficient, the movie selection adequate, and one of the flights even provided me with vegan meals. The latter was all thanks to my more responsible girlfriend. </p> <p>I arrived at the hotel in Nairobi late, well past sunset. Despite the dark hour, I could tell the grounds were beautiful, and the lone songbird that could not seem to fall asleep added to the ambiance. </p> <p>After a good night of rest, the dependable driver from Naomi Cabs stood outside, ready to take me to Kijabe. This is the same man who stayed at the airport three hours past when my flight was supposed to land. I felt such appreciation for him when I noticed my last name written on a piece of paper with marker, walking out from the terminal with a small Jansport backpack, and no other luggage, as it stayed back in Chicago. It would be five days until my bags found their way back to me.</p> <p>The hour-long drive along both smooth and potholed roads to Kijabe was my first glimpse into a piece of Kenyan life. From Kibera, the largest slum in Kenya, to the estates hidden behind trees. From the masses walking along the highways to the competition cyclists squeezed into their tight gear. The preceding three months were part of the rainy season, so this part of the country is as green and lush as it ever gets. </p> <p>The driver effortlessly avoids nearing cars, people, cyclists, and the ever-present motorcycles that drive on the side of the road against the flow of traffic. While he keeps us safe and moving toward our destination, I am focused on the people living outside. There are people and shanty stalls along almost the entire length of road from Nairobi to Kijabe. Stalls selling fruits, meats, and wares repeat in endless fashion, with donkeys grazing on the grassy spaces between.</p> <p>Kijabe, Maasai for “Place of the wind,” is a small town that is perched at 7,000 feet on the edge of the Great Rift Valley. It has a population of over 17,000 people, but if someone asked me to take a guess, I would say no more than a thousand people live here. Homes must be hidden throughout these hills and behind the trees that I cannot see. Kijabe hospital, the reason for my coming to Africa, is located in Kijabe Mission Station. This area is also home to AIC-CURE Children’s Hospital of Kenya, Rift Valley Academy, and a number of other religious schools and organizations.</p> <p>I first meet with Helen who shows me to the humble accommodations that will be my home for the next three weeks. It is a new dorm called “Elimu,” which is Swahili for “education.” On its opening day, an official from the government came to witness it. This is not uncommon in Kijabe Mission Station. The hospital here is a source of pride, and the president himself has come on several occasions to see to the opening of hospital operating theatres and wards. </p> <p>A woman, who’s name I do not know, tirelessly cleans the common area, washes the dishes, does our laundry, cleans our bathroom, and even changes our sheets once per week. She comes from a town in the south of Kenya called Kajado, but moved to Kijabe eleven years ago when she got married. I am endlessly grateful for her. I would be living in a pile of muck if not for her endless drive. </p> <p>Luke, one of the most seasoned KRNAs spent the morning showing me around the operating theatre. He brought me through each of the eight operating rooms and the endoscopy suite. He took me to the pharmacy, storage rooms, PACU, showed me where the ultrasound machine should be returned to, and of critical importance, where morning chai is served. </p> <p>Chai, tea with milk, is engrained in the Kenyan culture. Some prefer it sweet, while some unsweetened. In practice, a mixture of the two seems to achieve a mild and pleasant sweetness. Chai breaks are looked forward to, as well as expected to arrive. </p> <p>The caseload and variety at Kijabe Hospital is impressive. In the five days I have worked there, I have taken part in caring for parturients undergoing cesarean deliveries, cancer patients having brain tumors removed and limbs amputated, seemingly endless children with hydrocephalus undergoing VP shunt installations, and even a ruptured iliac aneurysm that arrived in the operating theatre near midnight.</p> <p>Many of the KRNAs are thirsty for knowledge, consistently bringing up cases to discuss, and seeking advice on performing regional anesthetics for both surgery and postoperative pain control. The resources at Kijabe, albeit limited, are far better than I expected, and from what I have been told, better than almost every other hospital in Kenya. In the past week, we placed a thoracic epidural in a four-year-old patient that underwent an exploratory laparotomy for complications of Hirschsprung disease, and lumbar catheter for a woman who had to have a hip disarticulation for a rare and aggressive cancer.</p> <p>My timing here is fortuitous in a number of ways. I have arrived in Kenya as the rainy season is ending, leaving a green and blossoming country with clear blue skies in its wake. There are also two national anesthesia conferences this month. The first was in Addis, Ethiopia, while the second will be held in Mombasa, Kenya.  If this was not enough good fortune, it so happens that the observers of the Greek Orthodox religion in Ethiopia were fasting during my brief time there.</p> <p>Unlike the fasting during Ramadan, when Muslims abstain from eating during daylight hours, the Greek Orthodox in Ethiopia only abstain from eating meat and chicken. This, therefore, results in restaurants and hotels serving an expansive variety of vegetarian and vegan dishes.  </p> <p>Mark Newton, Ban Sileshi, Matt Kynes, Joash, Mary, Allen, and myself landed in Addis, Ethiopia early on a weekday morning to give us enough time to set up and run the pediatric simulation course for the 9th Annual Conference and CME of the Ethiopian Society of Anesthesiologists. I spent this time napping, as I had been in the operating theatre with an emergent case up until we disembarked for Addis. </p> <p>Over the following days, we all participated in providing lectures and workshops to assist the Ethiopian society of Anesthesiologists in educating their residents and faculty. It was intimidating, gratifying, and fulfilling. It was also delicious. Ethiopian food, particularly during fasting, is excellent. </p> </div> <div class="field field--name-field-lockdown-auth field--type-string field--label-above"> <div class="field__item">1</div> </div> Thu, 13 Jun 2019 18:00:20 +0000 grewelj 754 at https://www.vumc.org/anesthesiology Allison Janda https://www.vumc.org/anesthesiology/blog/allison-janda <span class="field--node--title">Allison Janda</span> <span class="field field--name-uid field--type-entity-reference field--label-hidden"><span lang="" about="/anesthesiology/users/grewelj" typeof="schema:Person" property="schema:name" datatype="">grewelj</span></span> <span class="field field--name-created field--type-created field--label-hidden">Sun, 06/02/2019 - 13:03</span> <a href="/anesthesiology/blog-post-rss/755" class="feed-icon" title="Subscribe to Allison Janda"> RSS: <i class="fa fa-rss-square"></i> </a> <div class="text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><p><em>These blog entries are the views and opinions of the residents during and after their international experiences, and do not necessarily reflect the opinions or positions of VIA or VUMC.</em><br /> <br /> <strong>Week 1</strong><br /> Hello from Kijabe! Week 1 is in the books and we are settling in to our new role here in Kijabe. The night before we started in the hospital, Melissa, Sandy, and I poured through our textbooks, refreshing our brains on the doses and mechanisms of thiopental, pancuronium, halothane, and other drugs we don’t use at home. </p> <p>When we arrived to the operating theaters on our first day, we were greeted warmly by Mary, an excellent KRNA who gave us a tour and introduced us to the other KRNAs and students. She evaluated the OR board, which is a large dry erase board in the main hallway of the OR suite, and assigned us to one of the eight ORs for the day.  She assigned me to OR 8, an orthopedics room staffed by a newly graduated KRNA and two very junior students. It was the junior students’ first day in the Kijabe ORs as well! The anesthesia crew in OR 8 was incredibly welcoming, and the two junior students were very excited to learn. I glanced at the drugs nicely laid out on the ventilator. Much to my relief, propofol, rocuronium, and other very familiar drugs filled in the syringes, and they also had an isoflurane vaporizer, whew! I then looked at the monitor and ventilator screen. The KRNA noticed my confusion when my eyes settled on the ventilator screen filled with question marks and alarms. </p> <p>He laughed and said that the tidal volume measurements and alarms had been non-functional for a while now, and they confirm appropriate tidal volume administrationand O2 flow by watching the bellows. It took a few cases for me to get used to the lack of calibrated or accurate ventilator settings and we had a discussion with the new students about handling dangerous issues without alarms to notify you of the leak or lack of free gas flow.</p> <p>The eager new students had a whole packet of learning objectives and discussion points to cover. There were plenty of orthopedic topics to cover and, although it was their first day in the operating theater, they had great questions to follow up with during our discussion. The students hailed from all over Kenya.  One grew up an hour drive east of Nairobi, so three hours from Kijabe. The other student in my room was originally from a smaller town outside of Nakuru, about a six hour drive from Kijabe. Both would live here and then go back to their small towns after they completed their 18 month training. They spoke about how they were excited to bring back their knowledge to their small hospitals and help the people they grew up with. It was awesome to teach these new students on their first OR day knowing that they would soon be scattered across Kenya.</p> <p><strong>Week 2 </strong><br /> Hello again! We are thoroughly enjoying our time in Kijabe in and out of the OR. Last weekend, we had a group of visitors to the Kijabe theaters over brunch. Two pediatric attendings from CHOP, Grace and Jonathan, arrived the same day we did (the were actually on the same flight!), and one of the Vanderbilt general surgery residents, Gretchen, overlapped with our time in Kijabe as well. We went to the Supa Duka on Friday and were excited to find fresh eggs for omelets. We then went across the road to the market to pick up some fresh vegetables to mix in.   On Saturday, Melissa made some delicious omelets and the six of us visited, talked about the past week, and played a card game. It was awesome to get to know these amazing people more and hear about their previous experiences visiting different hospitals throughout the world.   We also had fun watching the baboons play in a patch of grass near our house and jump on our porch and roof before they were chased away by some neighbors. Apparently the baboons will try to get into open windows and will ransack your kitchen!</p> <p>On Sunday, we made a trip to Crescent Island and Hell’s Gate and it was absolutely amazing.   Crescent Island is a small crescent-shaped island in Lake Naivasha populated by non-predator animals and is ideal for hiking. Our very enthusiastic driver, Philip, picked up Gretchen and the three of us bright and early and whisked us off towards Lake Naivasha. Throughout our drive down into the Rift Valley, the fog lifted and our first stop was a boat launch that took us on a little trip around Lake Naivasha to see some hippos and birds and then to Crescent Island. The hike through the island was incredible. We were able to walk feet from giraffes, zebras, impalas, and wildebeest. It was great to explore unencumbered by paths, fences, or barriers whatsoever between the animals and us. </p> <p>After confirming that the nearly constant rains from the week before hadn’t washed out any roads near Hell’s Gate, we set off in that direction. We rented bikes near the park entrance and biked on the road to get to the official park gate and then to the gorge. Our Masai tour guide for the gorge, Joseph, told us about his life and Masai history as we climbed down into the gorge, kindly telling us exactly where to put each foot as we went so we didn’t tumble. The gorge frequently flash floods and also has quicksand so hikes must be lead by a Masai tour guide to avoid any issues. The bike back from the gorge hike was beautiful as well, and Philip delivered us safely home to Kijabe.</p> <p>In the operating theaters this week, we encountered some challenging cases and very sick patients in the ICU while on call. It was stressful but fun being a true consultant without an attending anesthesiologist to add their impression or approve our plan. The students this week were six months into their training and were great to teach in the OR. We gave lectures on subspecialty anesthesia topics and they had much more advanced questions than the newer students. It was impressive to see how much the group had learned during their first six months and great to hear their stories of previous Vanderbilt anesthesia residents teaching them how to intubate or put in IVs. It was another great week of eager learners and I hope we helped advance their knowledge and skills.<br /> <br /> <strong>Week 3</strong><br /> Hello again! We have wrapped up our time in Kijabe and are now on the plane back to the US. I can’t even begin to describe what an amazing experience this has been. The KRNA students were such eager learners in the OR, but we also learned an incredible amount from them, the KRNAs, and the OR teams. </p> <p>This photo is from a pediatric case where I was working with and teaching a junior KRNA, Teddy, about pediatric anesthesia. The circulator, Andrew, is also in the photo and he was absolutely amazing at pediatric IVs on the smallest babies and was always ready to help us start the case. It was wonderful to work with junior KRNAs like Teddy for more challenging cases to help prepare them for anything that came their way.</p> <p>Sandy, Melissa, and I also took a photo with Mary on our last day. She is one of the head KRNAs at Kijabe and basically runs the show. Mary was the person who welcomed us to the ORs on our first day, and we were sad to say goodbye. She is an amazing person, anesthesia provider and teacher who could not have been more welcoming to us residents.<br /> <br /> Prior to going to the airport, we had a few fun stops along the way! We went to an elephant sanctuary, the Giraffe Center, and a market to spend the last of our Kenyan shillings. We had a great time watching the baby elephants eat and feeding the giraffes pellets of food. The giraffes were definitely the highlight of they day, they were incredibly friendly if you had a pellet in hand!</p> </div> <div class="field field--name-field-lockdown-auth field--type-string field--label-above"> <div class="field__item">1</div> </div> Sun, 02 Jun 2019 18:03:12 +0000 grewelj 755 at https://www.vumc.org/anesthesiology Drew Maynard https://www.vumc.org/anesthesiology/blog/drew-maynard <span class="field--node--title">Drew Maynard</span> <span class="field field--name-uid field--type-entity-reference field--label-hidden"><span lang="" about="/anesthesiology/users/grewelj" typeof="schema:Person" property="schema:name" datatype="">grewelj</span></span> <span class="field field--name-created field--type-created field--label-hidden">Tue, 05/14/2019 - 08:43</span> <a href="/anesthesiology/blog-post-rss/64" class="feed-icon" title="Subscribe to Drew Maynard"> RSS: <i class="fa fa-rss-square"></i> </a> <div class="text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><p><em>These blog entries are the views and opinions of the residents during and after their international experiences, and do not necessarily reflect the opinions or positions of VIA or VUMC.</em><br /> <br /> <strong>Week 1</strong><br /> I felt myself getting nervous for Kijabe a week prior to departure. I had traveled abroad many times prior, even on a non-medical, faith-based mission, but never this far away from home, or to the African continent. But as the 24 hours of air travel drew closer, I found my thoughts of the unknown turn toward excitement. With great fortune, our journey to Kijabe could not have been more flawless, aside from the expected jet lag which by our third day in Kenya is all but a languishing memory.</p> <p>The day following our arrival, Cosmos, our soft spoken driver transferred us by minivan from Nairobi up several thousand feet in elevation to Kijabe. As we ascended, we passed many roadside communities bustling with people, as well as dozens of matatus until we ultimately turned a corner when Kijabe and the Great Rift Valley below revealed itself - a spectacular view.</p> <p>Our walk up the hill from our three-bedroom anesthesia home complete with a perfect Mt. Longonot vista to Kijabe Hospital is drenched in the hot April sun and shrouded in cooler mountain air. The hospital was buzzing with patients who surely traveled many hours to be evaluated by local and international caretakers in the emergency room, clinics, dental office, hospital wards, ICU, and of course, the operating room. Dr. Kynes introduced us to dozens of operating room staff, including, KNRAs, student KRNAs and three Ethiopian anesthesia residents who have been rotating here for several weeks.</p> <p>After introductions, I went into OR 2 to assist with a chiari repair in an unusually older-aged presentation from what I came to know by US training. It is usually diagnosed in infants and children. He was a 40-year-old man who presented with upper and lower extremity spasticity. When I walked in, the student KRNA, Samuel, showed me an ECG with lateral ST depressions from a pre-op ECG three days prior. These were still present on the monitor. Unknowing what further assessment tools were at my disposal I started by having Samuel interpret, in Swahili, questions regarding the man’s medical history. A repeat 12-lead ECG minutes later showed the same ST pattern, so we decided to cancel the case and order some additional tests. Though the troponins would take another four hours to return from the lab, I had expected much greater resource limitations than what I experienced in that encounter. He could also be evaluated by echo later that day by a Nairobi cardiologist who comes to Kijabe on Mondays. We were still able to adequately evaluate the patient, delay and obtain further valuable information, including assessment of possible undiagnosed congenital heart disease, which in such a setting could go unnoticed for years, just like his chiari. The outpouring of people training and donating time in Kijabe is heartwarming and much needed.</p> <p>From morning to afternoon, I find myself pacing from the PACU to OR 1 through OR 9 and back. I assist with procedures, like the much more common spinal anesthetic to difficult airways in the ENT room and teaching peripheral neve blocks to the Ethiopian residents. There have been so many learning and teaching opportunities to an already well experienced KRNA staff. I can’t wait to get back to the OR tomorrow, but first my day starts with a lecture to the students.<br /> <br /> <strong>Week 2</strong><br /> Time, as usual, is passing quickly. It is already our second week here in Kijabe, and everyday I become increasingly comfortable and confident in my anesthetic practice within this low-to-middle income, rural setting. Several thought provoking events, including the one below provoked reflection about the methods of anesthetic practice compared to the USA.</p> <p>Earlier this week, I was called to assist in theatre nine regarding a hypoxic 23 year-old female who was five days post motorcycle collision. She arrived in Casualty (aka the emergency room) earlier that day with two lower extremity long-bone injuries, each to her femur and tibia, for external fixations. I arrived to find her saturating 88 percent on room air, tachypnic, tachycardiac and tearful. I introduced myself, then sat her up and placed her on oxygen, which helped somewhat, but I was still concerned, specifically about an embolism in her lungs. Upon further assessment, she was previously unable to obtain a CTA chest due to inability to come up with the payment. Despite this, surgery was scheduled and she was brought to the OR. I quickly contacted the surgical team to discuss my concerns, get more information and understand the urgency of the case. I also was able to perform a bedside echocardiogram while my Vanderbilt surgical colleague ultrasounded the patient’s lower extremity looking for a DVT. These evaluations were reassuring in that the biventricular function appeared hyperdynamic, but normal, and without right ventricular dilation. In the same token, there was no apparent DVT.</p> <p>Additionally, and upon further discussion, the surgery was determined to be non-urgent. However, the question remained whether a costly CTA would provide benefit to this patient, and whether she could get through surgery and anesthesia safely. Ultimately, given the patient’s perioperative risk, the ability of Kijabe Hospital to perform additional necessary workup, and taking into account the patient’s long distance from home we postponed the case.</p> <p>Personally, after reflecting on this case for the past few days I found great value in this experience. First and foremost is the expectation of doing what was right for the patient based on many factors, including the hospital setting and resources available. From what I’ve learned, Kijabe, as a leader in East African medicine, is in the unique position to provide a level of care similar to a high income country, albeit with a far more restricted budget. To me, the decision came down to do no harm, both financially and physically, to the patient. Without significant hemodynamic compromise her anesthetic would have likely been uneventful, though at an increased risk. It was also not warranted to proceed urgently, nor was it safe for her post- operatively without knowing more diagnostic information, and the potential for directed therapy. The hospital has small, but additional alternative methods to assist in the cost of care. Additionally, and amongst several other learning points, it was uniquely remarkable how every member of the OR team communicated risks, benefits and opinions all the while interpreting our discussion and decisions to the patient. Every voice, many from around the globe, was heard in a clear and respectful manner, which can be challenging at times to find in ORs at home. It was also an intense moment where a unique group of providers with varied training came together to help a woman in her time of tearfulness, anxiety and pain to do what was best, so she could get back to her loved ones and life in rural Kenya.</p> </div> <div class="field field--name-field-lockdown-auth field--type-string field--label-above"> <div class="field__item">1</div> </div> Tue, 14 May 2019 13:43:34 +0000 grewelj 64 at https://www.vumc.org/anesthesiology Calvin Gruss https://www.vumc.org/anesthesiology/blog/calvin-gruss <span class="field--node--title">Calvin Gruss</span> <span class="field field--name-uid field--type-entity-reference field--label-hidden"><span lang="" about="/anesthesiology/users/grewelj" typeof="schema:Person" property="schema:name" datatype="">grewelj</span></span> <span class="field field--name-created field--type-created field--label-hidden">Tue, 04/30/2019 - 10:05</span> <a href="/anesthesiology/blog-post-rss/66" class="feed-icon" title="Subscribe to Calvin Gruss"> RSS: <i class="fa fa-rss-square"></i> </a> <div class="text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><p><em>These blog entries are the views and opinions of the residents during and after their international experiences, and do not necessarily reflect the opinions or positions of VIA or VUMC. </em><br /> <br /> <strong>Week 1</strong><br /> Prior to beginning this first blog post, I reviewed the many other “first” blog posts from my predecessors. While each traveler’s first week on the job has been unique, I have also appreciated many themes that were repeated over the months and years since this blog began.</p> <p>Like those before me, I boarded my flight from Nashville to Chicago with excitement mixed with a tincture of anxiety. While I have been abroad before and worked in underserved communities, each experience has been so different that I have learned to never make assumptions regarding the destination or job responsibilities.</p> <p>From Chicago, we took an eight-hour flight across the Atlantic to London. We grabbed some coffees and croissants and prepared for our next leg of the trip, another eight-hour flight from London to Nairobi. Surprisingly we breezed through customs, grabbed our luggage from the turnstile, exited security, and found our driver without a single issue. Tired from travel, we arrived at the Methodist Guest House in Nairobi, checked into our rooms, showered, and fell asleep without issue.</p> <p>The following morning after a well-deserved night’s rest, we hopped back into our driver’s van and made our way to our final destination, Kijabe, Kenya. We stocked up on groceries along the way and were blow away by the “instagramable” landscape that existed from every window of the vehicle. The views only got better as we approached our destination as we weaved through the valley to our accommodations within the Kijabe Hospital community.</p> <p>Arriving at Roller (the name of our 3-bedroom home for the next month), we were relieved to have completed our journey here and excited for the possibilities and opportunities that awaited us these next four weeks. Chad, Drew, and I grabbed some chairs, headed to our front yard, and watched our first Kenyan sunset still a little in disbelief of how lucky we were for this once-in-a-lifetime adventure.<br /> <br /> <strong>Week 2</strong><br /> One Thursday evening, coming from across the house we heard our hospital-issued phone ringing. At first, we thought nothing of it as we had received many calls throughout the week regarding orientation meetings with personnel in Kijabe.</p> <p>Chad jumped up and made his way through the dining room to the kitchen where the phone was ringing on the counter. From the moment he answered, the tone of the evening shifted. Both Drew and I gleaned that something concerning was underway. Within 15 seconds, Chad had hung up the phone and told us there was an emergency at the hospital. While he had trouble discerning what was being said on the other end of the line, we all knew we needed to head to the hospital immediately.</p> <p>We threw on our scrubs, grabbed our stethoscopes, locked our door, and bolted towards operating theater 6. When we arrived, we found a young woman, intubated, unresponsive, with a questionable rhythm on her EKG. Together as a team we immediately began collecting data from the providers in the room and attempted to distill what had transpired prior to our arrival, just as we had been trained while on call at Vanderbilt Medical Centers over the past three years.</p> <p>Our first question, “Do we have a pulse?” No clear answer was heard; Chad quickly felt for a femoral pulse and could not feel one. Working under the assumption of PEA, we began chest compressions, called for the code cart, and readied the appropriate medications we would require (epinephrine, bicarbonate, calcium).</p> <p>Concurrently, we elucidated the following information from the in-room providers:</p> <p>    32-year-old female<br />     4-weeks postpartum<br />     Recent hematemesis episodes of unclear etiology requiring an EGD<br />     EGD had been scheduled emergently<br />     Recent echo showed cardiomyopathy and an EF of 12-15% w/ MR</p> <p>With ACLS underway, we began brainstorming possible etiologies. After working through a differential and covering the standard Hs and Ts, we suspected that she had coded on induction secondary to propofol and had underlying severe cardiomyopathy.</p> <p>After nearly 20 minutes of chest compressions, several rounds of epinephrine, sodium bicarbonate, and calcium, the patient regained a perfuseable rhythm and was safe for transport to the ICU. With our limited resources, we transported the patient with a pulse oximeter while palpating the femoral artery, holding an epinephrine infusion above the patient to flow by gravity, and wheeling an oxygen cylinder behind the patient while hand-ventilating her.</p> <p>We had worked hard and provided this patient with the best possible care we could provide in this setting. She is currently resting in the ICU under the supervision of ICU physicians there. We hope and pray that she makes a full recovery.</p> <p>    Welcome<br />     Education<br />     Patient Care<br />     Intranet<br />     Research<br />     Recruitment<br />     Global<br />     Health<br />     Outreach</p> <p> </p> </div> <div class="field field--name-field-lockdown-auth field--type-string field--label-above"> <div class="field__item">1</div> </div> Tue, 30 Apr 2019 15:05:28 +0000 grewelj 66 at https://www.vumc.org/anesthesiology Sara LaRosa https://www.vumc.org/anesthesiology/blog/sara-larosa <span class="field--node--title">Sara LaRosa</span> <span class="field field--name-uid field--type-entity-reference field--label-hidden"><span lang="" about="/anesthesiology/users/grewelj" typeof="schema:Person" property="schema:name" datatype="">grewelj</span></span> <span class="field field--name-created field--type-created field--label-hidden">Mon, 04/22/2019 - 10:12</span> <a href="/anesthesiology/blog-post-rss/68" class="feed-icon" title="Subscribe to Sara LaRosa"> RSS: <i class="fa fa-rss-square"></i> </a> <div class="text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><div class="barista-posts-teaser-with-image col-xs-12"> <div class="text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"> <p><em>These blog entries are the views and opinions of the residents during and after their international experiences, and do not necessarily reflect the opinions or positions of VIA or VUMC.</em></p> <p><strong>Week 1</strong><br /> This first week in Kenya (and the travel journey preceding it) has been all about rolling with the punches, and finding joy in the adventure (and misadventure).</p> <p>Starting with last Saturday, the trip did not exactly start off on the right foot when our flight was delayed leaving Nashville, ensuring we would miss our connecting flight in Chicago for the leg of the trip to London. We managed to get on the flight leaving two hours later in the evening (phew!)….but then, guess what? That flight got delayed because of “mechanical issues”, and the miniscule layover we were going to have at Heathrow with this flight quickly disappeared (oy vey!).  And here’s the thing, there’s only one British Airways flight from London to Nairobi everyday. The four of us all travelling together (myself and Sarada, as well as Cat and Dr. Sizemore from OB) started plotting the grand adventures we were going to have with our extra day in London. Once we got to London, it turns out everyone had already been automatically rebooked on flights. Everyone else had been rebooked on a Kenya Airways flight leaving later that day while I was the only one who had been booked on the British Airways flight the next morning. Not wanting to leave me alone in London, the rest of the group made sure they could get booked for the British Airways flight the next morning as well, which turned out to be a multi-hour affair (there went all of our grand plans for London).</p> <p>We did eventually make it to a very nice hotel for the night, had some good Indian food and a good night’s sleep, and got on the final leg of our trip the next morning.  We all made it safely to Nairobi on Monday night. Unfortunately our bags didn’t (because of course they didn’t with the way our travels were going).</p> <p>Luckily the cursed travel saga is pretty much where the negative stuff ends, and even that part ended up being more hilarious than anything because we all had each other to commiserate with. We all had a pretty good attitude about it all.</p> <p>We made it to Kijabe. Our bags eventually came, things are settling in well, and it’s honestly starting to feel like a little bit of a home away from home.  At the hospital, I’m honestly still trying to feel out my place and my role, but am enjoying the process. The KRNAs and students have been lovely to get to know. I am already seeing so much potential for growth and learning for myself through the processing of working here these next few weeks and looking beyond to my last couple months of residency and transition to being an attending.</p> <p>Chai time at the hospital is one of my favorite parts of the day. It’s mostly milk, with a little bit of tea, and it’s a welcome warm mug of comfort that breaks up the day nicely. I mostly get the unsweetened version because I’m not a huge sugar fan (and kind of a health nut), but sometimes I pour in a little of the regular kind for an extra treat.</p> <p>Outside of the hospital, I’ve been trying to do as many of the “normal” things I’m used to doing to make it feel more like home (other than being on the internet, that is). It’s actually been very refreshing to disconnect a little and enjoy the small things. I do things like try to work out or do yoga when I wake up. I found a blender in our kitchen cabinets a couple days ago and was super excited to make one of my Almond milk and peanut butter banana greens smoothies I make at home with some local produce we’d got. I also love cooking healthy meals at home, and so this past Friday I made a family dinner for the house!<br /> <br /> After a hilariously rough travel adventure and first few days of adjusting to life in Kijabe, we decided to make the most of our weekend off with some fun adventures.  Saturday, we made our way out near Lake Naivasha to Crescent Island.  We did a boat safari and saw a whole bunch of Hippos, and then spent some time walking around an island and getting way closer than I thought possible to zebras, giraffes, and some other cool animals.  We decided to treat ourselves to a nice lodge in Naivasha for Saturday night, which was SO worth it.  Delicious full board meals, a comfy bed, and drinks by the pool. Yes please! The time for relaxation was necessary, because when we woke up early Sunday morning, we set off to hike Mt Longonot. Let me tell you, it was quite a challenge but nothing beats the hard-earned view when you make it to the top!<br /> <br /> Now it’s Sunday night and we’re safely back at Kijabe. All the dusty mess we kicked up all over ourselves during our hike is cleaned up. We are refreshed and ready for another week at the hospital.  I am so excited about what I am going to learn from these Kenyan providers and how this experience may change and grow my own practice moving forward.  It’s only just beginning!</p> <p><strong>Week 2</strong><br /> It’s the end of our second week here in Kijabe and I feel like I’m really hitting my stride. I’m feeling, for the most part, at home both in and out of the hospital. I feel like I’m learning to work with some of the frustrations of not having all the resources and comfortable things I’m used to. However, as far as low resource settings go, Kijabe is actually doing quite well. I’m also finding myself more and more enjoying some of the simple pleasures around here.</p> <p>I had a couple of experiences this week in the theatre that really made me feel like “ok….. maybe I CAN do this whole ‘big kid anesthesiologist’/attending thing in a couple months.”  On Thursday afternoon, as cases were mostly wrapping up and I was getting ready to head out for the day, I stepped into the room to check on the providers for a uterine myomectomy (fibroid removal) that was going on. When I walked in, the patient’s heart rate was in the 130s and the systolic blood pressure was hovering around 55-60. Yikes!  It turns out that while the surgeons knew there was a large dominant fibroid, there was A LOT more than they had initially bargained for. I’ll spare you the photograph here just in case that’s not your thing, but trust me when I say the amount and size of fibroids that came out of this woman was ridiculously impressive or horrifying depending on your perspective. I quickly surmised that we had lost over 1.5L blood at that point (by the end of the case we would estimate our EBL was ~4L).  Along with one of the Kenyan Nurse Anesthetists, I directed and made a plan for resuscitation with transfusion (and pressors to temporize/stabilize of course). By the time we left the room, we were stable off norepinephrine and our heart rate was 80-90. #Winning. It was honestly such a great feeling to have accomplished all of that without relying on someone supervising me to assist.</p> <p>I also feel like some of the KRNAs and students are getting a lot more comfortable working with me (and vice versa) and just accepting me, which feels great. One of them taught me how to count to 10 in Swahili this week, as well as a few other words.  Apparently they were impressed with my quick learning. Who knew I had a hidden talent for picking up languages? Another one of the KRNAs tried to teach me a little bit of Kikuyu, a different local dialect, and says he is going to quiz me on it this week.</p> <p>Outside of the hospital, I have really been enjoying the gorgeous surroundings, the sense of community, and the slow pace of life here. Every Monday, there is dessert night that happens at one of the “long termers’” homes, and we went for the first time this week.  It was a wonderful evening to enjoy some snacks, tea, good conversation and fellowship with some of the other short and long-term people working here. I continued trying to make our anesthesia house feel like home and made “Taco Tuesday” for all of us this week. </p> <p>This weekend has been low key compared to our adventures at Crescent Island and Mt Longonot last weekend, but it has been so relaxing and wonderful. Yesterday, I was “on call.” I walked up to the hospital first thing in the morning and there weren’t any cases the KRNAs needed my help with, so I let them know to call me if anything came up, and proceeded to head back to the house. I decided to take advantage of the free day, beautiful weather, and gorgeous views of the Great Rift Valley from our backyard by grabbing a book, a chair, and some good music and podcasts, and parked myself outside for the entire morning to read and reflect. Wow, was that life giving for my soul!! I took a walk to the market in the afternoon to restock on some essentials and fresh produce. Hallelujah for 30 cent avocadoes! </p> <p>In the evening, Matt and Ansley Kynes needed to borrow my computer for a few minutes to fix some Internet issues, and ended up inviting me to stay for dinner, tea, and a few rounds of Dutch Blitz (so fun…you should play it right now).</p> <p>Today, I joined Matt and Ansley and the kids for church and lunch up at Rift Valley Academy. Now, I am just relaxing back at the house. We are starting to give lectures for the KRNA students this week, my husband comes next weekend (YAY!), and overall I am just looking forward to seeing how the second half of this experience unfolds.</p> <p>Tutaonana baadaye (that’s Swahili for “see you later”).</p> <p><strong>Week 3</strong><br /> I can’t believe we are three quarters of the way through this experience and my time in Kijabe is so close to being done! It has been quite an adventure and opportunity for growth.</p> <p>There have certainly been situations that have been frustrating, whether it’s perceived problems with efficiency, miscommunications, yearning for more resources; however, the goodness and the growth, both in my skills and my relationships built with the people here, have far outweighed those frustrations. I think I am genuinely going to miss being around the people here (and the beautiful views from our house and around the hospital) when I leave at the end of this week.</p> <p>Like I said already, I feel like this month has been huge for my growth and confidence, and I think both Sarada and I realized a lot of that growth the past Friday. Dr. Kynes was away from Kijabe and Dr. Barnett had some other administrative tasks to attend to for most of the day, so it was basically just the two of us, and it seemed like everything that could go awry with cases was doing so. We were really pushed to step up as the acting attending physicians and manage it (and I think we both handled it all pretty darn well).  </p> <p>One example was a case that came in for Direct Laryngoscopy and biopsy for a patient presenting with hoarseness. By all observable measures, there was no concern for a difficult airway, but when it came time to induce, we found ourselves unable to intubate with multiple attempts, including with the video assistance of the glide scope. We could get an optimal view, but had difficulty passing an endotracheal tube, or even a bougie.  Eventually, the surgeon had to help with a rigid bronchoscope to assist intubation, and it was at this time we discovered that the patient had much more severe pathology than expected based on her symptoms and exam. She had extensive subglottic fullness creating a severe stenosis, as well as a very small laryngeal opening for her size. The case proceeded smoothly once the airway was secured, but at the end of the case the patient woke up thrashing with some serious emergence delirium and ended up pulling out her IV. Luckily, I was able to secure a new one after a couple attempts even with her fidgeting about on the table.</p> <p>In another room, I had a child wake up from a tonsillectomy and have a severe laryngospasm following extubation, requiring administration of propofol and succinylcholine. He desaturated into the 20s (aka VERY BAD), but recovered with additional bag mask ventilation. He then proceeded to have the same reaction again, though I think he may have also had a bronchospasm, or possibly a small aspiration. His lungs sounded horribly rhonchorus and wheezy (when we could even hear air movement at all, that is). I ended up having the KRNA reintubate and give Albuterol through the ETT as well as suction down the tube. We were going to remain intubated and go to the PICU, but there was no bed available. Luckily, the child’s exam improved incredibly with the suction and Albuterol, and his lungs sounded much clearer. This time, we successfully extubated without incident and he ended up doing just fine.</p> <p>It was quite refreshing and empowering to handle these challenging situations (successfully, I might add) without a supervising attending to step in or guide.</p> <p>As we’ve tried to do for most of the time we’ve been here, we also managed to find some good time to relax, unwind, and have a little fun this week. We met a few 4th year medical students this week, and ended up having them over to the anesthesia house for dinner and game night on Saturday. I kept up with my trend of being the mom of the house and cooking healthy meals for everyone by making up a big batch of pork chili for us all (and it was spicy and DELICIOUS). Pair that with some Tusker lager and a few rounds of Crazy Eights and Bananagrams, and you’ve got a pretty fun evening of fellowship.</p> <p>We rounded out the weekend with a GORGE-ous Sunday adventure (pun 100% intended) at Hell’s Gate National Park and Gorge. We rented bikes at the entrance gate and biked 7km to the start of the gorge, passing zebras, giraffes, buffalo, and warthogs (what’s up, Pumba!!) along the way.  We spent a couple of hours hiking with our Massai guide through the gorge, and it was absolutely stunning! Heading into the final week now hoping to soak up whatever I still can!!</p> <p><strong>Week 4</strong><br /> Wow! I genuinely cannot believe how quickly this month at Kijabe has flown by! It has been an absolute joy working with the men and women here at the hospital and feeling like I at least have a small part in helping train providers and strengthen the ability to provide safe anesthesia for more and more patients in Africa.</p> <p> My husband came to join me at the beginning of this week, and it felt so natural just doing life with him in Africa (foreshadowing for a potential return trip with him for a longer stay??? Perhaps!!). He even got the chance to go down to the valley with an acquaintance of the Kynes family this week to an orphanage/school and really enjoyed it. It was wonderful and reassuring for him to quickly fall in love with Africa the way I have.</p> <p>It was harder than I thought to say goodbye to everybody on my last day of work on Wednesday, but so wonderful to have positive feelings from the KRNAs and students I had worked with throughout the month. A couple remarked that Sarada and I should stay, perhaps for at least a year they said. Pictured here are Luke and Bedjouk, a couple of my favorite hardworking friends.</p> <p>On Thursday, my husband and I left together to the Masai Mara for a safari, which was an awesome way to end our time in Africa together. We got a great deal through the hospital for a beautiful Full Board safari resort with beautiful tent accommodations, delicious food, and two daily game drives included! We saw all of the Big Five (Rhino, Lion, Elephant, Cape Buffalo, and Leopard) and had a wonderful time together!</p> <p>It was a looooong and for part of the way, a very uncomfortable and bumpy drive back from the Mara to Nairobi today. Thankfully, we arrived in Nairobi in time to head to Africa Yoga Project (one of my favorite studios in Nashville, Small World Yoga, modeled their non-profit/community yoga off of it) so I could move my body a little bit before getting to the airport for a full night of flying to our next adventure. We will vacation in Belgium and France before heading back to Nashville. Now I am parked at the Turkish Airlines lounge thanks to my Priority Pass membership (if you travel much, get yourself a travel rewards card with this perk…it’s SO worth it!). I’m enjoying a buffet of food, free showers, and beverages. I am grateful for all I have learned and gained this past month, and excited for what is ahead.</p> </div> </div> </div> <div class="field field--name-field-lockdown-auth field--type-string field--label-above"> <div class="field__item">1</div> </div> Mon, 22 Apr 2019 15:12:17 +0000 grewelj 68 at https://www.vumc.org/anesthesiology Chad Greene https://www.vumc.org/anesthesiology/blog/chad-greene <span class="field--node--title">Chad Greene</span> <span class="field field--name-uid field--type-entity-reference field--label-hidden"><span lang="" about="/anesthesiology/users/grewelj" typeof="schema:Person" property="schema:name" datatype="">grewelj</span></span> <span class="field field--name-created field--type-created field--label-hidden">Mon, 04/22/2019 - 10:09</span> <a href="/anesthesiology/blog-post-rss/67" class="feed-icon" title="Subscribe to Chad Greene"> RSS: <i class="fa fa-rss-square"></i> </a> <div class="text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><p><em>These blog entries are the views and opinions of the residents during and after their international experiences, and do not necessarily reflect the opinions or positions of VIA or VUMC.</em></p> <p><strong>Week 1</strong><br /> I walked into the operating theatre at Kijabe Hospital, ready to start my first case since arriving to this beautiful place far from home. I first met Frederick, a friendly man with an infectious smile who was working as the student KRNA (Kenyan anesthetist) in room nine that day. He greeted me with a warm embrace and we began talking to one another like we had been friends for years. Our first case was a cesarean section for a very pleasant young woman. Up until this point, the events leading up to the surgery seemed fairly routine and familiar. We spoke about her pregnancy, her medical history, her children at home, and her gratefulness for Kijabe Hospital. As we were talking, the obstetrician walked in and everyone gathered around the patient. And then, we prayed.</p> <p>Growing up in a Christian home, prayer had always been an important part of my life. We would pray before meals, before going to sleep at night, and when gathered at church for worship. Although hard to admit, my time in prayer had become routine, almost a checkbox to complete when it surfaced in my mind. Today was different though. It served as an important reminder of the incredible privilege that we have to approach the throne of God and pour out our hearts to Him. It wasn’t until today that I realized the powerful role that prayer could play in medicine— something stronger and better than any medication could provide. At a time that many are anxious or hurting, our faith allows us to rely on something bigger than any problem that may come our way.</p> <p>I love how the Kijabe people live their lives and embrace one another. I love how they share their faith freely, without fear of being judged, much how I imagine the first-century Christians lived. Never before had I taken part in such a pure and meaningful time of spiritual renewal and mediation with my colleagues at work. In that moment, I experienced the power of prayer unlike any time I had before. I witnessed the comfort that it gave my patient to see her surgeon and anesthesiologist pray over her. I felt the joy that it brought me, knowing that God was loved in this place so far from home, and I could feel the common bond that it created among everyone in the room, despite the cultural and language barriers that distanced us.</p> <p>The case went on and the patient and her baby did very well. As the day progressed, I met many other wonderful people. I continue to be amazed at how well the people of Kijabe work together and the kindness that they show in all that they do. From the anesthetists, to the surgeons and the nursing staff— everyone works toward a common goal in seemingly perfect harmony. There are no selfish ambitions, no hidden agendas, and the people here sacrifice so much for people they know very little.</p> <p>Although we have been here for only a few days, my experience has been more than remarkable. I’m amazed at the eagerness and willingness the Kijabe people have to learn new skills and further their knowledge. In such a short amount of time they have taught me so much as well. I am thankful for the opportunity to serve here and know this experience will stay with me for years to come. May God continue to bless this incredible work!</p> </div> <div class="field field--name-field-lockdown-auth field--type-string field--label-above"> <div class="field__item">1</div> </div> Mon, 22 Apr 2019 15:09:30 +0000 grewelj 67 at https://www.vumc.org/anesthesiology Sarada Eleswarpu https://www.vumc.org/anesthesiology/blog/sarada-eleswarpu <span class="field--node--title">Sarada Eleswarpu</span> <span class="field field--name-uid field--type-entity-reference field--label-hidden"><span lang="" about="/anesthesiology/users/grewelj" typeof="schema:Person" property="schema:name" datatype="">grewelj</span></span> <span class="field field--name-created field--type-created field--label-hidden">Mon, 03/25/2019 - 08:32</span> <a href="/anesthesiology/blog-post-rss/69" class="feed-icon" title="Subscribe to Sarada Eleswarpu"> RSS: <i class="fa fa-rss-square"></i> </a> <div class="text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><p><em>These blog entries are the views and opinions of the residents during and after their international experiences, and do not necessarily reflect the opinions or positions of VIA or VUMC.</em><br /> <br /> It was an adventure arriving in Kijabe, to say the least! Every leg of our flight itinerary added an extra flair to our story. Sara La Rosa goes into more detail about our escapades in her blog post, so I’ll just say that I am thankful that we made it safely (and eventually so did everyone’s luggage). I am also grateful for new friends (here’s looking at you Chris Sizemore and Cat Voorhees!) who made getting stuck feel like just another plot twist bursting with laughs and good company. The morning after we arrived, we met with Dr. Matt Kynes for our orientation to Kijabe Hospital. After our tour of the hospital, Sara and I each picked one OR to see the work flow. I picked OR 3, which typically is the OB/GYN room, because the in-room KRNA asked if I could help with TAP blocks for the hysterectomies scheduled later in the afternoon.</p> <p>My first case is a Cesarean section for di-di twins. The KRNA and I oversaw the student KRNA as she performed the spinal anesthetic. The spinal block set up well and we performed our time-out for the surgery. We prayed for the patient, introduced everyone on the anesthesiology and surgery teams, and reviewed the patient’s name as well as anesthetic and surgical concerns. When the babies were delivered, they were taken to a neonatal resuscitation room down the hall where they were examined by the pediatrics team. The KRNA left the room for a break and I stayed with the student after the babies were delivered.</p> <p>When the KRNA came back into the room, she asked me if I liked pediatric anesthesiology. She told me I could go down the hall to see the twins if I was interested. I walked over and saw that the second twin had been intubated and there was a large team struggling in a cramped room. I asked how I could help, and the doctor who was managing the airway asked me if I could get umbilical vein access. I had never done that before, so I tried my best to cannulate the saphenous vein in the legs but it was unsuccessful. We switched places and I took over the airway while he looked for IV access. I saw that our monitor showed that the baby’s heart rate was too slow and our oxygen saturations were around 60%. I started chest compressions and we called for help from the pediatric ICU. There were no available ventilators in the ICU, which meant there was nowhere to take the baby.</p> <p>And that was my first experience on my first day at the hospital. I prayed with the team and after a debrief I popped in and out of other ORs to see where I could be helpful. To be honest, I was looking for a menial task I could do to keep my hands busy and to ground myself. Anyone need an IV? Can I fetch something for you? It felt surreal to be walking in and out of the ORs. It felt like I was flipping through channels on a TV, and I felt detached as I watched each channel pass by. I was humbled by the limitations of what I could offer. I also felt paralyzed by how much our brothers and sisters in Kenya, and around the world, suffer in ways that I am lucky to have never experienced.</p> <p>Later in the day, I was able to shake off how stunned I felt and that’s when my stomach started grumbling. The daily routine includes Chai time at 10:30 AM and lunch at 2:00 PM. In between cases, the student KRNA asked me to follow her. She took me upstairs to the Chai room and told me to sit down. She made me a cup of Chai, my first one in Kenya. It was made with fresh cow milk and loaded up with sugar. The warmth and sweetness were comforting and it reminded me of when I visit my family in India. Cadi didn’t sit next to me; she told me she would be back. She opened her bag and gave me her chappati, which was her lunch and was meant to be eaten later that afternoon. She told me she could eat anytime, but I should eat now. I was so grateful for my first friend in Kijabe.</p> <p>When it was lunchtime, the KRNA took me to the Chai room again where lunch was served. Lunch was rice, lentils, and cabbage. The KRNA sat with me and she taught me again how to say her name. Bedjouk and I talked a little bit, rested a little bit more, and ate the most. We wrapped up our day and I headed home. The next day, Bedjouk found me at lunch and told me to open her bag. She brought me a banana. She told me she wanted to know how African bananas compare to American ones. As I ate it, she told me the story of how she loved a man she met in college, who was from a different tribe, and how her family’s house was burned down because of it. She had planned to marry someone else, who was of the same tribe, to save her family. But in the end, she married the love of her life and they moved from their hometown in South Sudan to Kenya. She worked during the week in Kijabe and on the weekends she visited Nairobi to see her husband and their beautiful 2-year-old daughter named Blessing. She showed me pictures of her wedding and her family on her phone. It was in this moment, eating an African banana in the Chai room and listening to a modern love story, that I saw the beauty of Kenya and how rich its people truly are.</p> </div> <div class="field field--name-field-lockdown-auth field--type-string field--label-above"> <div class="field__item">1</div> </div> Mon, 25 Mar 2019 13:32:54 +0000 grewelj 69 at https://www.vumc.org/anesthesiology Erica Adkins https://www.vumc.org/anesthesiology/blog/erica-adkins <span class="field--node--title">Erica Adkins</span> <span class="field field--name-uid field--type-entity-reference field--label-hidden"><span lang="" about="/anesthesiology/users/grewelj" typeof="schema:Person" property="schema:name" datatype="">grewelj</span></span> <span class="field field--name-created field--type-created field--label-hidden">Sat, 03/09/2019 - 08:49</span> <a href="/anesthesiology/blog-post-rss/65" class="feed-icon" title="Subscribe to Erica Adkins"> RSS: <i class="fa fa-rss-square"></i> </a> <div class="text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><p><em>These blog entries are the views and opinions of the residents during and after their international experiences, and do not necessarily reflect the opinions or positions of VIA or VUMC.</em><br /> <br /> <strong>Week 1</strong><br /> Day One: We landed in Nairobi early Tuesday morning after a very long travel adventure that included having our luggage lost and an unexpected night in Amsterdam waiting for it to catch up to us.  At the airport the customs and entry processes were very efficient and fast and before we knew it we were loading our things in a van and were off.  Matt Kynes and Claire met us at the airport with our driver, Phillip, and it was very comforting to see familiar faces.  We headed to a mall in Nairobi to buy groceries.  At this point Lauren and I were both starting to feel the severity of our jet lag.  We did our best to grocery shop for a couple of weeks but the food selection is certainly nothing like what we find in America!  We settled on the basics and are essentially praying we can just survive since we have no idea what to expect.  We FINALLY reached our house, which was quite a shock to me walking in. I don’t think it had hit me just how basic life was going to be here until I was putting the groceries away and Matt was explaining how to purify our water and wash our vegetables.  Don’t get me wrong, the place isn’t bad but it is lacking a lot of comforts.  That feeling of “what did I get myself into?” combined with sleep deprivation and jet lag was quite overwhelming to say the least.</p> <p>Ultimately, on that first day I felt overwhelmed.  Overwhelmed by the unknown, by the responsibility to provide good care to the people of Kijabe, by the homesickness I could already feel, and by the solitariness that I think comes with taking chances like this.  At the same time, I also just feel thankful that I have Lauren here with me; she could tell I was having a hard time today and did her best to cheer me up and I need her to be here with me to push me and to keep going in this adventure.</p> <p>Week One: The past few days have been quite a culture shock both professionally and personally.</p> <p>First off, on day two (first morning waking up in Kijabe) we awoke to find that we had no hot water and barely any water pressure, so poor Lauren suffered through a freezing cold, trickling shower and I hiked up to the Kynes’ house to shower very quickly before we were due at the hospital.  Once at the hospital we met Claire and Ansley as well as Matt and were filmed in various settings throughout the hospital as we toured and were oriented.  After a quick PB&amp;J sandwich at home, we both took naps, after which we felt like new humans.  We planned our next weekend trip to Lake Nakuru and had our orientation with Ann Rita who is super nice, then our filming continued by going to the Duka and market which were both pleasant surprises by the variety and quality of goods available.  After we finished filming we went to the Kynes’ for dinner from Mama Chikus (local restaurant with authentic Kenyan dishes), showered at their house, then came back and essentially went to bed.  Needless to say it was an exhausting day and the feeling of being overwhelmed continued to persist.</p> <p>The following day was better after a good night’s rest.  We discovered that our hot water worked!  Once at the hospital it was essentially trial by fire.  I jumped in with a KRNA (Royaus) and our first case was a lady with a pretty severe lip laceration extending into her nasal passage, we did an RSI and the KRNA got the airway with a bougie but the bougie was in his bag because he keeps his own personal bougie for difficult airways.  I then was called to another room for a difficult airway in a child with severe neck burns that had turned into the worst contractures I’ve ever seen that had literally pulled his lower lip and mandible down to his chin.  Our plan was an asleep intubation with a glidescope.  The patient turned into a difficult mask to the point that we desated to the 60s before Dr. Barnette shoved the ETT into the nose and positioned it just before the cords and we hooked the circuit to it and ventilated.  Once the patient recovered we used a glidescope to intubate the patient.  The second case I was involved in was back in Royaus’s room and it was a case of the worst fibrodysplasia I’ve ever seen to the point that the patient’s airway was completely occluded and had subsequently been trached previously and was blind.  At the point I got involved, the patient had lost approximately 800ml of blood and they had just begun so they were waiting on blood to arrive from the blood bank (the patient had 3 donors from the previous day) so that we could transfuse and they could continue.  We ended up transfusing 2 units of blood, giving TXA, and 1L fluid and the patient did fine but the feeling of being in charge in a very foreign environment with a critical patient was quite scary.</p> <p>So far everyday has been better than the day before.  At the hospital we are becoming more comfortable in our role as supervisors and helping the KRNAs and students to provide better anesthesia and becoming more familiar with what the hospital can offer.  Taking care of patients with debilitating problems you would never see in America and seeing how grateful and appreciative they are is really refreshing.</p> <p>Over the weekend we were able to take some hikes, see beautiful views, and encounter some monkeys both on the trails and on our porch.  We are also taking advantage of the simple pleasures here like M&amp;Ms, Snickers, and Coke Zero that we found at the Duka (convenience store), which is helping to sooth our homesickness. <br /> <br /> <strong>Week 2</strong><br /> It is the beginning of week three and the homesickness is starting to set in. I miss my dog, my family and friends, as well as just the convenience of being able to jump in my car and go to the store or to a restaurant. The days at the hospital have been quite long. We have been staying until 5 pm most days as well as lecturing in the mornings. I’ve really enjoyed giving the lectures because we have had the chance to get to know the students a little better and it makes teaching in the OR easier. The students are very hungry for knowledge which I find very refreshing and it has stimulated my own motivation to read more. The challenging and frustrating part of lecturing is most of the material in Morgan and Mikhail isn’t relevant to their low-income setting. So when giving the transfusion lecture we discussed blood components separately, but I’ve only seen whole blood transfused here because that’s all they have available. In the OR, the days vary from being really stimulating and enjoyable to very slow and feeling like I’m constantly wondering around looking for something to do. I’ve found that I mostly enjoy days when I have a case or room to focus on with difficult cases, whether that be comorbidities, interesting pathology, or difficult airways. The KRNAs are very excited for us to do regional blocks on patients and are also eager to learn themselves. This has been really nice for us to help with because it has allowed us to practice what we’ve learned from our regional rotations and see the results, which have been very positive. It is so gratifying placing a block by yourself and then seeing the patient in the OR with only nasal cannula on because your block was successful.</p> <p>Outside of the hospital, I am getting better accustomed to the “simple life.” Lauren and I make dinner most nights and I must say most of our meals have been quite tasty. We’ve also been back to Mama Chikus, but it wasn’t as good as the first time. After dinner we typically will try to watch a movie or read, either for pleasure or preparing for an upcoming lecture. Last weekend, we had the opportunity to get into some luxury; we took an excursion to Lake Nakuru and stayed in a resort for two nights inside Lake Nakuru National Park. The property was absolutely breathtaking and we were met with warm wash cloths and freshly squeezed mango juice to freshen up after the dusty 2.5 hour long trip. We went on a game drive into the park on Saturday and saw some amazing wildlife including rhinos, giraffes, zebra, water buffalo, hyena, gazelles, and plenty more that I’m sure I’ve forgotten. Back at the hotel we also treated ourselves to massages and a delicious dinner. It was a really nice way to unwind and refresh. <br /> <br /> <strong>Week 3</strong><br /> Week four, the final countdown! I am very ready to go home at this point. I wish that the rotation was still three weeks because I think the end of last week was the perfect amount of time. I am just ready to get back to my regular routine. Last week we did some interesting cases and there were some really sick people to take care of. One person in particular stands out, he was a 20-something male who sustained a motor vehicle accident and had known bilateral pulmonary contusions and rib fractures coming to theatre for acetabular fracture. We learned of him early in the morning and Lauren and I both went to see him along with the student KRNA. He was on 4L NC in the low 90s, but didn’t appear to have increased work of breathing, lying flat with a C-collar on so we felt it was appropriate to proceed. We had discussed with the surgical team that he would likely need an ICU bed following surgery as he might be challenging to intubate. The patient ended up being a very challenging airway due to his potential for C-spine injury and he was also difficult to oxygenate once intubated, only reaching a SpO2 of low 90s throughout the case on 100% FiO2 and PEEP of 12.  ortunately, likely because of his youth, he was otherwise hemodynamically stable and the surgery was done in an efficient manner. We decided that it would be best to leave him intubated and transport to ICU where he could be extubated there. The case finally finished at 8pm and we physically ran the patient to the ICU because we had no PEEP valve available and we were fearful that once taken off our ventilator he would desaturate rapidly. We also only had an SpO2 monitor for transport because that was all that was available, certainly not the way things are done at Vanderbilt.</p> <p>Over the last weekend we also had the amazing opportunity to go to the Masai Mara. We stayed at the Fairmont which is a luxury resort where you essentially “glamp” in really nice tents with large comfortable beds and an outdoor shower with very, very hot water and outstanding water pressure. It’s humbling how thankful I’ve become for simple things like that.  There were four game drives included in the stay and the sights we saw were absolutely breathtaking and incredible. A few of the highlights include seeing two male cheetahs eating a tempi; a male lion and lioness dragging a zebra kill into the bush; a leopard lounging in a tree; an elephant and her baby eating; two rhinos; three lion cubs playing and lots of lions sleeping.  It was fascinating how the animals were completely unbothered by our presence and would get surprisingly close to the vehicle.  The resort overlooked the Mara River, where there were 30 hippos that spent the afternoons in the river bathing. Then at night they would migrate down the river just beyond our tents, get out of the river and go to the plains to graze at night until around 5am when they would make their way back to the river. The funny thing was they made a lot of noise on their way back into the river and they sounded like a deep evil laugh just outside our tent. On the second night we also had the “pleasure” of hearing a bush baby all night; it makes a terrible pecking noise followed by a series of screams that literally sounds like it’s dying. Between the hippos and bush babies we determined that although the Fairmont was a very relaxing escape from Kijabe, it isn’t a place one should go to get peaceful sleep. <br /> <br /> <strong>Week 4</strong><br /> As this month comes to an end, I am trying to reflect on the experience and what influence I may have had on others, as well as how this experience has changed me. I think it’s easiest to break it down into categories to really get a good understanding but knowing that all of them blend together.</p> <p>Professionally, I think this experience has been both really beneficial from some clinical aspects, but also very challenging in others. By helping out here I have had the opportunity to see some incredibly challenging airways due to very unique or advanced pathologies that we don’t see in the US.</p> <p>Two cases stick out specifically in my head. The first was an extremely cachectic man suffering from a very advanced squamous cell carcinoma of his posterior tongue that presented for PEG tube placement prior to starting chemo/radiation therapy. He was brought to theatre and initially the decision was made to do a modified awake intubation with good localization and ketamine then DL or glidescope. Unfortunately, with manipulation of the airway he began to bleed as well as have increased swelling. Multiple attempts were made at intubation but were all unsuccessful. So the decision was made to abort the procedure that day, wake the patient up, give steroids for airway edema and attempt an awake fiberoptic the following day. When he re-presented to the theatre, we were prepared for awake nasal fiberoptic which went smoothly. I was able to get the scope into the trachea, however, when we advanced the tube the fiberoptic was pulled out of the trachea due to the inability to pass the ETT. At one point we had even lost an ETT in the posterior pharynx which I have never heard of happening.  Eventually we were able to stabilize his airway and he got his PEG tube along with a tracheostomy. While it was an excellent learning experience for me, I felt like a very serious palliative care conversation should have been had with this patient because, given his very poor state of malnutrition and the fact that his tumor was unresectable, I’m not sure going through all that he went through was beneficial given he will likely not tolerate chemo/radiation.</p> <p>The second case is a child with a rhabdosarcoma of his tongue that was presenting for resection. Again, a nasal intubation was planned with glidescope however we found that the glidescope handle was too large to fit the McGills in the back of the mouth and visualize and manipulate the ETT too. We switched to DL but with the insertion of the blade the friable tissue from the tumor began to bleed making the airway very bloody. The patient began to have brisk bleeding and impressive bloody emesis so nasal intubation was aborted and essentially with blind insertion of a bougie and oral ETT was established. The surgeon eventually was able to visualize and stop the bleeding from the tumor and place a nasal ETT.</p> <p>This rotation has also allowed me to practice my regional skills, especially upper extremity blocks in a way that I think is hard to do at Vanderbilt. Here I’ve been able to use my own judgement about where the best view is and how much local to put where and then evaluate whether or not my block is working without an attending standing over my shoulder dictating exactly where my needle tip should be in their opinion, which has given me a lot of confidence about my ability to perform regional as an attending.</p> <p>In addition to challenging airways and regional anesthesia, there are also challenging decisions that must be made in regard to resource allocation and realistic outcomes. We had a 20-something year old patient transferred from an outside facility for appendiceal abscess and sepsis that had progressed to severe necrotizing fasciitis extending from his knee up into his retroperitoneum. The surgeons brought him to the theatre for debridement and he was hemodynamically stable throughout the procedure. However, the following day he ended up maxed out on norepinephrine and dopamine infusions. Given his instability the surgeon came up to examine the wound at bedside and determined that his injury was too extensive. He would need further debridement to survive, but wasn’t really stable enough to travel to theatre and given the spread into his abdominal wall his recovery, would be too challenging. The entire time with that patient in the ICU, I couldn’t help but think how this scenario would have been different at Vanderbilt. If we only had access to vasopressin infusion maybe his hemodynamics may have been better and able to tolerate further debridement.  </p> <p>While the clinical cases have been a really great experience, it has been frustrating at times because I feel like our presence here has been met with some opposition. There are certainly some that are very happy to have us help and make suggestions but there are others who would prefer we stay away and our suggestions are met with a lot of resistance if it is outside the norm of typical practice. This mentality is also reflected in some of the students. Part of me can understand their hesitance to accept us because we are just visitors for a short period of time and with or without us they have to continue to take care of the patients the best way they know how. I think what is frustrating is that it makes our role as residents so ambiguous that often times I feel superfluous.</p> <p> </p> <p>Personally, this month has been very taxing for me as it is the longest I’ve ever spent away from my family and friends. It’s not just from a physical distance standpoint but also the time difference makes it hard to communicate with them because at times when I am home after work they are typically asleep and visa versa; it feels very isolating. In addition to that, it is the first time I’ve ever been submersed into a different culture, especially one that is so opposite from my lifestyle at home. After the initial culture shock wore off, I was fine and even at times I’ve enjoyed the simplicity and quietness in Kijabe. For the most part, the people in Kijabe are very friendly and welcoming.</p> <p>All in all, this has truly been an adventure for me and looking back I am very happy that I’ve been given this amazing opportunity to participate. There are many things that I will take back from here and use in my practice as an anesthesiologist in the future as well as a better appreciation for not only the amenities that accompany my lifestyle in the US, but especially  the access to top notch healthcare within minutes away.</p> </div> <div class="field field--name-field-lockdown-auth field--type-string field--label-above"> <div class="field__item">1</div> </div> Sat, 09 Mar 2019 14:49:36 +0000 grewelj 65 at https://www.vumc.org/anesthesiology Lauren Poe https://www.vumc.org/anesthesiology/blog/lauren-poe <span class="field--node--title">Lauren Poe</span> <span class="field field--name-uid field--type-entity-reference field--label-hidden"><span lang="" about="/anesthesiology/users/grewelj" typeof="schema:Person" property="schema:name" datatype="">grewelj</span></span> <span class="field field--name-created field--type-created field--label-hidden">Mon, 02/18/2019 - 08:35</span> <a href="/anesthesiology/blog-post-rss/70" class="feed-icon" title="Subscribe to Lauren Poe"> RSS: <i class="fa fa-rss-square"></i> </a> <div class="text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><p><em>These blog entries are the views and opinions of the residents during and after their international experiences, and do not necessarily reflect the opinions or positions of VIA or VUMC.</em><br /> <br /> <strong>Week 1</strong><br /> It is both liberating and frustrating to be here providing medical care and instruction in Africa. Liberating from the everyday hustle and bustle of a busy American life with constant working internet and incessant emails and ads and posts. Frustrating in that it is hard to figure out my place here and then establish that role with a modicum of respect for those who are here all the time. I find myself just thinking out loud as a means of teaching because sometimes I don't know who's who in a room and sometimes it's hard for me to understand the accent, so I don't want to be rude and ask several times. I understand that although I have brought with me a deeper fund of knowledge and higher skill set, I am still the visitor here. The people here have operated before me and will continue to operate after I am gone. They are doing their best to provide the best care they can with the tools and knowledge they have. No good can come from forcefulness. If I do not show respect, no learning can be had.</p> <p>I know they can teach me too. I have much to learn being in the attending role, as I learned today. I was proud of myself thinking I had thought of everything and had us all check that we had the necessary tools, calculated the right dosages for the induction and then lo and behold--I did not check that the student had the right size blade for laryngoscopy. Some of this comes from my assuming that their carts are as well stocked as ours back home (which they are not). We bagged the child while someone ran around the other ORs looking for the appropriate size blade and once that happened--turns out the light didn't work on the handle! So someone else had to run around looking for a new handle. Luckily, bag mask ventilation wasn't difficult, but I felt like a failure. That was ultimately my responsibility.</p> <p>Being an attending is like being the parent in the room and over here it's like being the new babysitter your mom called last minute because your regular beloved babysitter was busy. I will say the students/KRNAs consider what I'm saying instead of outright ignoring me. The KRNAs are knowledgable and most are welcoming and eager to learn, especially regional blocks. I will admit I've been using the regional blocks to butter the KRNAs up. I feel like I'm sort of "on their turf" and thus need to be extra nice so that maybe they won't hate it when I speak up about something I see. I typically try to be inquiring when I see something that is concerning rather than confrontational, but even this is questioning their ways of doing things. I know that is why we're here, but again this is not my house. I wonder if I would feel like this if I were a man... I am learning something everyday and becoming more comfortable waltzing into a room and assessing a situation, but we will see what the next weeks bring.</p> <p>As for Kenya in general, I love the simplicity of life here. I like walking to and from work and cooking almost all of my meals. The weather is perfect, cool in the morning and evening and warm during the day. The scenery is breathtaking and I even love the red dirt. It adds such color to the scene, although I think about parasites that might live there a lot. Evenings are peaceful albeit a little lonely without my usual crew around. I wonder what I will look forward to the most about getting back. My least favorite part about living here is the water, but at least it's running! But living in fear of severe diarrhea everyday is a little stressful to me. I bleached our veggies and fruits the other day and found myself obsessing over whether all the sides of the apples had enough time in the bleach water. I also obsessed over keeping my mouth shut in the shower and constantly blow air out to make sure none of it gets in! Also, I like cooking and Mama Chiku's is great, but I'm going to want Chipotle again at some point... and what I wouldn't give for a cold brew from Starbucks! #basic.</p> <p>I think this experience will change me in a lot of ways. Not only will it further my training, but I think I will declutter my life when I get home and take more time and pride in the simple things I used to enjoy, like I do here now such as cooking and cleaning the kitchen--things I always feel I have no time for because I need to study or pay bills or answer emails or workout or rush around to do some other thing that seems more urgent. Or who knows, maybe I’ll forget I said this and revert back to my neuroses within 2 weeks of return. Hopefully, what I leave here with the Kenyans will last longer than that.<br /> <br /> <strong>Week 2</strong><br /> Over the past few weeks, I have been challenged with scenarios I have never seen before or cases I have dealt with, but this time with different resources. It is satisfying and stimulating to come up with plans for these scenarios and see them through successfully. We lost a patient yesterday. Even though we had done all we could. He was 30 years old. I find myself thinking of him often throughout the day. He looked to be on death's bed when I first took him to the OR. I don't think different resources would have saved him, but my regret is that we didn't give him a little time with his family before taking him back. We were the last faces he saw before we closed his eyes for what ended up being the final time. I know it is hard to predict, but maybe when we know a case is close to futile, we should pause.</p> <p>I am grateful to be working as a doctor here. I have felt closer to my passion since I left. Things are in a way, simpler here. I think because I don't have a car. With a car comes a lot of other responsibilities and errands to run. Here I just walk to work and back. I can focus on just medicine and the sunset. However, when you do need a car here, it is a very unpleasant experience in my book. Kenya is very dusty and there is no AC so you ride with the windows down... my hair has never felt nastier. Cant even try to comb it, it's straight to the shower! Also, many of the roads are very jaunty. They're mostly dirty roads with huge potholes from the rain and any major roads are still only 2 lanes. The drivers are aggressive about going into oncoming traffic to pass someone. It takes two to three times as long to get anywhere than it should because of these obstacles. Additionally, there are patrols along the roads that will stop your driver randomly to question them about whether they have all the right equipment or not. There are also people standing in the middle of traffic trying to sells snacks and bottled water. The housing and shops along the road are a reflection of destitution. The nicest building we saw on our way to Lake Nakuru was our own lodge! Makes me wonder why a country so beautiful with so much natural resource is so underdeveloped. Our little trip made me grateful we are staying in Kijabe where it is beautiful and seems to be a little cleaner. We still have the best view in the house. <br /> <br /> <strong>Week 3</strong><br /> We started lectures. It is so refreshing to have a crowd that is genuinely interested and has read the material. They ask good questions and are clearly thirsty for knowledge. I hope that we are delivering on that as well as they'd hoped. I have been learning a lot too, mostly about myself. Self-doubt is a bad seed that can paralyze you. I cannot let that happen. I became a doctor to help others; it will do no good to doubt and hesitate. I must live more in the moment. We have had many situations here that require a quick-thinking leader and a lot of times they look to us. I am honored, but I had some days that my fear of inadequacy threatened to overcome me. I hope this is something that also gets better with time. On the flip side, I think it's great to question yourself. It's the only way we improve and avoid unnecessary risk.</p> <p>This country is so beautiful. We went to the Masai Mara this weekend and saw the Earth in all its majesty. We woke up to the hippos making their way back to the water and a bush baby who kept trying to die... at least that's what it sounded like. With all it's beauty, it is still so wild and it makes me grateful for where I come from.<br /> <br /> <strong>Week 4</strong><br /> As I sit here and watch the sun set on our last night in Kijabe, I find myself sad that I'll be leaving this beautiful, peaceful place. I'll miss the sunsets, the cool mornings, the colorful flowers, the simplicity of life. Here, I just got to be a doctor and nothing else. I walked to work and back every day, cooked dinner every night, and had time to read for education and for pleasure. I felt the pressure of everything else lift when I got here and I was finally able to be what I have worked all my life to be without distraction. Navigating transitions is always tricky, but I think I handled it pretty well this time.</p> <p>I think the best thing about this trip is that I got to make my own plans for patients and see them through from difficult airways to pain plans. The autonomy was nice to know that I'm not going to harm someone. I am capable.</p> <p>It is amazing to me how passionate people here are about learning. Maybe it's because they know they will be practicing on their own after only 18 months of training in a rural area, so it is just that more intense, but it's refreshing and inspiring to see all the same. I think we take our education for granted in America. I have been so lucky to be able to become what I am. I confess I am not a very religious person, but the medical prayer stuck out to me the first day I was in the medical director's office in Kijabe Hospital: "It is indeed a tragedy of circumstances, my Lord, that my livelihood involves meeting people with unbearable pain. But also, it is my good fortune that you have given me this excellent opportunity to mitigate their suffering. You have cast upon my shoulders this great responsibility and have also given me dexterity to do it." Being able to serve here has brought back my appreciation for medicine and my role in it. It has chased my cynicsm away. Kijabe brought me back to life through its earnestness, purity and sincerity. We are all here in medicine to serve patients; it is our gift and our duty, no matter what the title. We all play a part, have our strengths, skills, and weaknesses. Together we can make a better world, piece by piece, through sharing our knowledge, our tools, and our spirits.</p> </div> <div class="field field--name-field-lockdown-auth field--type-string field--label-above"> <div class="field__item">1</div> </div> Mon, 18 Feb 2019 14:35:38 +0000 grewelj 70 at https://www.vumc.org/anesthesiology Jared Cummings https://www.vumc.org/anesthesiology/blog/jared-cummings <span class="field--node--title">Jared Cummings</span> <span class="field field--name-uid field--type-entity-reference field--label-hidden"><span lang="" about="/anesthesiology/users/grewelj" typeof="schema:Person" property="schema:name" datatype="">grewelj</span></span> <span class="field field--name-created field--type-created field--label-hidden">Mon, 02/04/2019 - 08:46</span> <a href="/anesthesiology/blog-post-rss/72" class="feed-icon" title="Subscribe to Jared Cummings"> RSS: <i class="fa fa-rss-square"></i> </a> <div class="text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><p><em>These blog entries are the views and opinions of the residents during and after their international experiences, and do not necessarily reflect the opinions or positions of VIA or VUMC.</em><br /> <br /> <strong>Week 1</strong><br /> We arrived in Kijabe Sunday afternoon. As soon as we started on the drive up from Nairobi, I was amazed at both how beautiful the country is and also how remote the area around Kijabe is. We turned off the main road, and after another 30 minutes down a dirt road filled with potholes, we arrived at the small village of Kijabe.</p> <p>The first day or two we spent primary getting settled into our surroundings. We had to figure out little things, like learning how to filter water, bleach our fruits and vegetables, and how to keep baboons out of our windows (they weren't joking!)</p> <p>As soon as we arrived in Kijabe, we were greeted by so many wonderful people from the hospital. Our first couple of days were full of folks dropping by our house to check on us, welcome us, and make sure we had everything we needed.</p> <p>The first part of the week was a little difficult in the hospital—we spent the majority of our time getting oriented to the system and finding our role. Overall, anesthesiology in Kenya is very similar to the US—similar anesthetic plans, induction sequences, OR flow, etc. but the differences were what took some getting used to.</p> <p>Being in a low resource setting where every dollar matters, supplies such as LMAs and bougies are washed and reused between patients. Temperature and neuromuscular monitoring doesn't exist. The machines are "well used" with inoperable oxygen and flow sensors, no end tidal volatile anesthetic monitoring. It's an interesting challenge to be able to cross check that you are delivering sage care without as much information. Similar to flying a plane with partial avionics panel failure.</p> <p>Our decision making and skills have already been tested. So far, we've already troubleshooted ventilator failures, difficult airways, circuit leaks, hemorrhagic shock in an 8 year old, urgent cesarean deliveries... all with Brett and me acting as true anesthesiology consultants. Additionally, we routinely see advanced pathology that I've only seen in textbooks.</p> <p>It's a humbling honor to be able to be here to provide whatever insight I might have. The patients are incredibly grateful for their care and are some of the nicest people I've met.<br /> <br /> <strong>Week 2</strong><br /> I enjoy the challenge of limited resources. It's requires me to really think critically to create a plan with fewer monitors and fewer drugs. I also respect the vast limitations of training and knowledge, my 8 years compared to their 18 months. One of my patients’ alarm was sounding in PACU for a SpO2 of 74%. I'm used to being stat called to bedside, with a team of pannicked nurses around bagging the patients, grabbing airway bags, asking me if we should reintubate. Instead, here, the nurses are more laid back. When asked about it, they respond, "oh well she looks okay." A SpO2 of 74% is never okay.</p> <p>I'm struggling to understand why a limited resource setting can't still be an efficient system that provides good care. There's a severe lack of ownership over outcome here. I don't know how to teach folks to actually care about doing a safe anesthetic. And that's what's frustrating. That's what makes me discouraged, and leaves me filling stressed after work.</p> <p>This weekend we are going on safari in Massai Mara. It will be a great weekend away for some needed relaxation and time to enjoy this beautiful country.</p> </div> <div class="field field--name-field-lockdown-auth field--type-string field--label-above"> <div class="field__item">1</div> </div> Mon, 04 Feb 2019 14:46:41 +0000 grewelj 72 at https://www.vumc.org/anesthesiology Brett Shaffer https://www.vumc.org/anesthesiology/blog/brett-shaffer <span class="field--node--title">Brett Shaffer</span> <span class="field field--name-uid field--type-entity-reference field--label-hidden"><span lang="" about="/anesthesiology/users/grewelj" typeof="schema:Person" property="schema:name" datatype="">grewelj</span></span> <span class="field field--name-created field--type-created field--label-hidden">Mon, 02/04/2019 - 08:44</span> <a href="/anesthesiology/blog-post-rss/71" class="feed-icon" title="Subscribe to Brett Shaffer"> RSS: <i class="fa fa-rss-square"></i> </a> <div class="text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><p><em>These blog entries are the views and opinions of the residents during and after their international experiences, and do not necessarily reflect the opinions or positions of VIA or VUMC.</em><br /> <br /> <strong>Week 1</strong><br /> Jared and I arrived in Kijabe early Sunday morning. We stayed in Nairobi the first night in a nearby hotel and woke up to a lovely breakfast, then had a stroll to a local market to get ingredients for the first week of dinners. We had an approximately one hour drive to Kijabe from Nairobi and got to see beautiful landscapes and scenery along the way. The main road/highway quickly turned from a busy urban setting to rural, with the occasional police checkpoint. We quickly arrived to the dirt roads and potholes of Kijabe and knew we were near the hospital.</p> <p>The first evening we settled in our new home and toured the hospital. The "anesthesia house" is surprisingly large—a 3 bed, 2 bath home with all of the necessary utilities. We enjoyed a well-seasoned pasta dish with Italian sausage followed by a much-needed rest.</p> <p>The next day we woke up and went directly to the hospital. The ORs were starting and we started our primary roles: ensuring patient safety and assistance with teaching the Kenyan anesthetists. Jared and I familiarized ourselves with not only (new to us) old drugs used, but also a miscellaneous collection of ventilators, all with different knob locations, switches, and controls. We felt fortunate that we only had to learn the mechanics and operation of one type of anesthesia machine and ventilator at a time in the US.</p> <p>Another prominent difference we've noticed in patients here has been the rarity of the patient with numerous comorbidities. Patients tend to have one primary issue for which they require surgery; for instance amputation for diabetes, thyroidectomy for hyperthyroidism, removal of a neurofibroma. Whether this is because many conditions are less frequently diagnosed here or patients tend to be healthier, time will tell.<br /> <br /> <strong>Week 2</strong><br /> Over last weekend Jared and I traveled to Naivasha and Lake Nakuru, where we experienced safari by vehicle, water, and walking. The safari experience was amazing and we saw numerous species including zebra, impala, waterbuck, water bull, rhinos, hippos, countless birds, velvet monkeys, baboons (one of which jumped into our van!) Fun fact, "safari" in Swahili translates to "journey" in English.</p> <p>In addition to our safari exploration, Jared and I were excited to expand our wireless connectivity with Safaricom cellular service. We can now download Netflix movies and watch them in the evening. We're basically at home now in Kijabe!</p> <p>Patient care has of course continued throughout the week, along with countless assessments of senior KRNA students who are nearly ready to finish their curriculum. We continue to see pathology that is much more advanced and untreated here in Kijabe compared to Nashville. This is commonly in the form of a mass/tumor that has advanced distortion of airway anatomy, presenting unique consideration for anesthetic management.</p> <p>Jared and I have taken on the morning lectures for KRNA students. Every morning we run an hour-long lecture to either teach or review concepts that students have had difficulty understanding. It's exciting to see students progress and apply the content they've learned throughout the week to their clinical practice.</p> </div> <div class="field field--name-field-lockdown-auth field--type-string field--label-above"> <div class="field__item">1</div> </div> Mon, 04 Feb 2019 14:44:43 +0000 grewelj 71 at https://www.vumc.org/anesthesiology Melissa Bellomy https://www.vumc.org/anesthesiology/blog/melissa-bellomy <span class="field--node--title">Melissa Bellomy</span> <span class="field field--name-uid field--type-entity-reference field--label-hidden"><span lang="" about="/anesthesiology/users/grewelj" typeof="schema:Person" property="schema:name" datatype="">grewelj</span></span> <span class="field field--name-created field--type-created field--label-hidden">Sat, 06/02/2018 - 06:57</span> <a href="/anesthesiology/blog-post-rss/756" class="feed-icon" title="Subscribe to Melissa Bellomy"> RSS: <i class="fa fa-rss-square"></i> </a> <div class="text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><p><strong>Week 1</strong><br /> We have just completed our first week at the AIC Hospital in Kijabe, Kenya and it has been a life-changing experience so far. My classmate Allison met me in DFW to start our journey to London then Nairobi.  Our travel was uneventful and we made it safely to the guesthouse where we stayed the night in Nairobi. This was my first time seeing mosquito netting! <br /> <br /> Upon arrival to Kijabe, we met our wonderful host, Helen, who gave us the most delicious zucchini bread!! Our home for this trip is the “Anesthesia House,” which is located on the edge of the community with a gorgeous view of the Rift Valley and Mount Longonot! <br /> <br /> Our first week in the OR or as they call it here, the “theatre,” was action-packed. We jumped right in and started working with the KRNAs, senior students, and new students on their first day OR day. One of my favorite parts of this trip so far has been the opportunity to teach both in the theatre and in morning lectures. The students are refreshingly hungry for knowledge and ask the most thoughtful questions. It is not uncommon to be sitting with a group of three or four students, drawing out the neuromuscular junction on one of their tablets and going through all of the different drugs. <br /> <br /> My second day started with a difficult airway. The patient was a young man with a mandibular tumor that had been growing for 9 years! I have encountered many difficult airways during residency, but this is the first time that I was in charge with no attending back up. The lack of resources (including a fiberoptic bronchoscope) made this extra challenging, but with some creative laryngoscopy and teamwork with the surgeons, we got him intubated safely for his incredible reconstruction. <br /> <br /> The most eye-opening experience so far has been ICU call. The ICU at Kijabe hospital only has five beds and four ventilators, so there are many difficult decisions to be made. Thankfully, the attendings here have been very helpful consultants for these ethical issues. Patients here present very late in their disease process and often times we are meeting them peri-arrest, but it is encouraging to see how well the ICU team manages these critical patients. <br /> <br /> After an eventful clinical week, we went to the market “Supa Duka” and got supplies to make a delicious omelette brunch on Saturday for the three of us and two attendings visiting from CHOP. It was nice to have a taste of home (cheese!) and spend some time in fellowship with fellow doctors from the USA.<br />  </p> <p><strong>Week 2</strong><br /> We have just wrapped up another exciting week in Kenya! Our week started off with an African adventure full of beautiful sights, wild animals, and great hiking. Then, we spent the rest of the week working in the “theatre,” which is becoming more familiar now.</p> <div> </div> <div>This Sunday, we joined with Gretchen, a surgical resident from Vanderbilt, to see what Kenya is like outside of Kijabe. We woke up early in the morning and drove about an hour to Lake Naivasha and took a boat to the Crescent Island animal sanctuary. We were the first ones there and got to see all of the animals in their morning routine. There were giraffes, zebras, gazelles, wildebeests, and even hippos! </div> <div> </div> <div>Then, we went to the nearby Hell’s Gate National Park for the most beautiful bike ride I have ever taken. We rode through the valley, which was the inspiration for the movie Lion King (we got to see pride rock!!) down to the gorge. There, a Masai tribesman named Joseph led us on a very challenging and slippery hike. He told us stories about his life, how he walks 15 km to work every day, speaks to the wildlife in his native language, and gave us information about the geology of the region. <br /> <br /> When we returned to the theatre for the second week, we finally started to hit our stride. Now that we are familiar with many of the KRNAs, students, and staff and have learned where the supplies live, it has become much easier to get things done. Also, we have embraced mid-morning “Chai time” tea plus some “chapatti,” a tortilla-like bread from the cafeteria, which has helped us survive until lunch at 2 p.m. We have begun to cover two rooms each day, acting as attendings (or as they say, “consultants”) for cases and also performing blocks. It is very satisfying to hear from the patients and the surgeons how much more comfortable everyone is on POD1 because of our blocks! <br /> <br /> Also, Dr. Newton has been around the hospital this week and is teaching us about the different regions of Kenya and their various healthcare needs.  It is so inspiring to hear from him and the lead KRNAs about their educational efforts throughout the country. <br /> <br /> I rounded in the ICU on Saturday, then we wrapped up the week with homemade breakfast and laundry. We have a washing machine, which is great, but no dryer so we took advantage of the first sunny day in a while to line dry our clothes. Also, I got this picture of Allison, which was too good not to share.<br /> <br /> <strong>Week 3</strong><br /> We are currently sitting in the Nairobi airport at the conclusion of an amazing, eye-opening, and life-changing trip.   <p>Our week started out with a bang! We were on ICU call Sunday, but Dr. Newton was so kind and covered the unit after rounds so that we could explore.  We drove out to Mount Longonot for a day hike and did not know what we had gotten ourselves into! The hike up was a challenge, since many of the trails had been washed out from all of the rain this season. However, once we made it to the top, it was all worth it. The views from the crater were absolutely breathtaking! </p> <p>It turns out that the hike up and back down around the crater (we only went half way and back due to dangerous terrain) ends up being 10 miles and 150 floors! After, our driver took us to "Java House" to replenish our glycogen stores :) This chain is owned by an American and we were so happy for a little taste of home.</p> <p>This week in the theatre was quite eventful, but 3 patient stories stick out in my mind:</p> <p>1) I had the opportunity to care for a young woman who had travelled all the way from Sierra Leone to have a mandibular tumor removed.  Her mouth opening was essentially nothing, so we anticipated a difficult airway. Unlike my first week, Dr. Newton was there and able to access the fiberoptic bronchoscope! He walked me through his way of performing an awake intubation. This was my first time performing a trans-tracheal injection and it really helped! We were able to get the patient successfully intubated and her surgery proceeded without incident. </p> <p>2) Another patient story that touched my heart was a woman who came for a scheduled cesarean section.  We performed the spinal and the surgery began as per usual, then we got to talking. She asked me to tell her the sex of the child. This is abnormal in Kenya, as most mothers want to see for themselves after the baby is resuscitated and cleaned. She went on to explain to me that she had lost a baby girl a few years ago and had been praying for a girl since. When the obstetrician birthed a screaming baby girl, we both shared tears of excitement. This patient had been through so much pain in her life and it was touching to watch the pure joy and peace that she was experiencing during her delivery.</p> <p>3) I also got to care for several children with hydrocephalus, while they got their VP shunts.  One baby in particular stuck out to me. He was 5 months old, but only 4.5 kilograms. The poor baby was extremely malnourished.  He was our last patient of the day so after surgery, I got to hold him for a while.  He was initially inconsolable, but he took to my finger like a bottle. It was very sweet but sad. </p> <p>At the conclusion of our trip, we packed our bags and headed to Nairobi. Since our flight doesn't leave until late tonight, we stopped by several places in town to experience ambit lord of Kenya before we leave.  We got to see baby elephants at the elephant nursery and we fed the giraffes with our hands at Giraffe Manor. It was so wonderful! </p> <p>Thanks for following along with our journey to Kenya.  This has been an amazing experience.  I hope that we were able to serve the patients in Kijabe and leave the KRNAs and students with a few helpful tricks so that they can continue to improve the practice of safe anesthesia in Eastern Africa. As they would say in Swahili, Asante sana!</p> </div> </div> <div class="field field--name-field-lockdown-auth field--type-string field--label-above"> <div class="field__item">1</div> </div> Sat, 02 Jun 2018 11:57:02 +0000 grewelj 756 at https://www.vumc.org/anesthesiology Okwuchukwu Obi https://www.vumc.org/anesthesiology/blog/okwuchukwu-obi <span class="field--node--title">Okwuchukwu Obi</span> <span class="field field--name-uid field--type-entity-reference field--label-hidden"><span lang="" about="/anesthesiology/users/grewelj" typeof="schema:Person" property="schema:name" datatype="">grewelj</span></span> <span class="field field--name-created field--type-created field--label-hidden">Thu, 03/29/2018 - 07:00</span> <a href="/anesthesiology/blog-post-rss/758" class="feed-icon" title="Subscribe to Okwuchukwu Obi"> RSS: <i class="fa fa-rss-square"></i> </a> <div class="text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><p><strong>Week 1</strong><br /> Lessons from the First week at Kijabe Hospital</p> <div class="center-block mc__width__limit" id="site-wrapper"> <div id="site-canvas" style="height:100%;"> <div id="site-content"> <div class="row" id="the_body"> <div class="col-xs-12" id="hero_image"> <div class="col-sm-9 20 add_middle_col_padding_right"> <div class="big-module sectioncontent clearfix" id="section-1"> <div class="innermodule clearfix"> <div> </div> <div>“TIA: This is Africa” Is one of the basic tenets to guide you while you work here at Kijabe Hospital. This nugget of wisdom was conveyed to us on our first day of orientation, and has been repeated several times over the course of my first week here in Kijabe Hospital by physicians who permanently work here at Kijabe. It is a simple way of saying: get your expectations in order; there are limited resources available so work with what you have. </div> <div> </div> <div>This principle has guided me on a daily basis: Everything is reusable. The ventilator circuits, the pulse oximeter probe, even drugs, which are drawn up into big syringes, then into smaller ones in order to have a clean syringe for each patient. </div> <div> </div> <div>Not withstanding limitations in resources, lives are saved daily in Kijabe Hospital. Here is a quick summary of the cases I participated in on Friday, 03/16.</div> <div> </div> <ul> <li>35 YO with Left breast cancer, for radical mastectomy</li> <li>28 YO elective cesarean section  <ul> <li>The same patient returned to the OR 2/2 post-partum hemorrhage for an emergent laparotomy that resulted in a hysterectomy  </li> </ul> </li> <li>​24 YO with Type 1 diabetes with SBO for emergent ex-lap</li> <li>45 YO with hx of HIV and uterine cancer for hysterectomy</li> <li>2 uneventful elective cesarean sections </li> </ul> <div>These patients were adequately cared for with the available resources, and represent a fraction of the surgical cases that were performed on Friday. This is Africa. A little goes a long way, and that is perfectly okay.<br /> <br /> <strong>Week 2</strong><br /> Lessons from Kijabe: Pray <p>We pray before every case. We pray with the patient in their language of choice, usually English or Swahili. The whole team consisting of the surgical team, anesthesia team, and nurses participates. It is usually a short prayer, led by anyone in the team. Attention is required; we intercede on the patient’s behalf. We pray for a higher power to guide the surgical and anesthesia team during the surgery. We pray for a smooth operation and uneventful post-op course. After the prayer, the anesthesia team proceeds with induction. If not done prior to anesthesia induction, we pray prior to “time-out”, at the beginning of the procedure.  In the Intensive Care Unit, we pray before we round on the service. We pray before any major procedure or intervention on a patient. </p> <p>AIC Kijabe Hospital was established over a century ago. It is a church affiliated hospital established by African Inland Church (AIC). Their mission is to “Glorify God through compassionate health care provision, training, and spiritual ministry in Christ Jesus”. It’s tradition of praying in the operating theater, ICU, and wards stems from it Christian background and continues to hold strong. </p> <p>These moments of prayer have been a point of reflection for me. </p> <p>I am reminded that a fundamental purpose of a physician is to be of service to other human beings. When we pray with our patient, we cast aside personal egos and focus on what matters: the patient. We acknowledge the privilege to use our education, wisdom, and judgment to care for a fellow human. We recognize our limitations as physicians, as humans without super natural power. </p> <p>Praying with a patient does not absolve us of our responsibility to be the best physician we can be; rather, it reminds us of said responsibility and holds us accountable to a higher power.  </p> <p>When we pray with our patients, we put them on equal footing with ourselves, the providers. We are here: for you, with you. </p> <p>It is different here in Kijabe. We pray openly, revealing our vulnerabilities as humans, understanding that we or a loved one will be the patient one day. </p> <p>In the United States, I have never offered to pray for my patient. Once in a while, I encounter a family who wants to pray and I willingly join them. They are usually grateful afterwards, strengthening our bond. I do not intend to change this practice. I will, however, try to make it a practice to offer a prayer for my patients in my mind. To remind myself to be of service to my patients: It is not about me, my time, or my convenience, but to serve a fellow human being in their moment of vulnerability. Understanding it is just a matter of time…</p> </div> </div> </div> </div> </div> </div> </div> </div> </div> </div> <div class="field field--name-field-lockdown-auth field--type-string field--label-above"> <div class="field__item">1</div> </div> Thu, 29 Mar 2018 12:00:09 +0000 grewelj 758 at https://www.vumc.org/anesthesiology