February 4, 2020

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.

Blog 1
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.

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.

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.

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.

The first part of the rotation has been an amazing experience thus far, and I look forward to the rest of it!

Blog 2
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.

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.

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.

morris