Caroline Ruminski

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 One
We just finished our first full week in Kijabe! As anticipated, it has certainly been an adjustment—but in the best way possible. Each member of the Kijabe community has welcomed us with the most genuine warmth and kindness, and I am already learning so much, not only about the ways they provide perioperative care to their patients, but even more importantly, about the way they treat every human as a brother or sister and view every living being with respect.

Our journey to Nairobi and ultimately Kijabe was smooth. We only lost one bag (which still has not arrived!), but we are making due. Monday morning, after a night’s stay in Nairobi, our new friend, Phillip, picked us up to travel to Kijabe. Sylvia gave us a tour of the Rollar home, where we’ll be living for the month. Next, we explored the hospital and the market and then got settled before heading to the Kynes’ for dinner.

On Tuesday, after a brief orientation, we dove right into patient care and teaching. So many had described how kind and curious all of the KRNAs and nurse anesthesia students are, but I was still immediately taken aback by how after just a few short minutes of knowing them, it seemed as if we were already close friends. I had so many questions about why they run 100% FiO2 for every case, where to find suction tubing, and what kind of pressors are available to us if we need them, but all of those would have to wait, because they immediately started asking me questions! My first case with my Theatre #3 team was a shoulder arthroscopy and we were planning to perform an interscalene nerve block post-operatively. This small, yet significant, portion of the anesthetic plan sparked a discussion that divulged into an entire lecture on every brachial plexus nerve block! I was so nervous about teaching coming into this experience—how will I answer questions if I’m not prepared? And what if I don’t have access to my typical sources for looking these answers up? But I quickly realized that every piece of knowledge is valuable and appreciated by these brand new students.

The KRNAs and students are assigned to a theatre for the entire week. Even though we met them on a Tuesday, it seemed as if they were already perfectly in sync with the other providers in the room. The juniors are brand new—having just started their clinical anesthesia time just a few weeks ago—and many of them have amazed me with their knowledge base, basic anesthesia skills, and general feel for the art of this practice. They are extremely dedicated to their patients—one of the junior students, Titus, stayed after his classmates left, because “I cannot leave—my patient is on this table.” They value every learning experience, which is truly an example to me. We take so much of our training for granted, and even resent it at times. I hope that the next time I am frustrated with a difficult case or “lack of supplies” (in quotations, because I will never perceive any of our “shortages” as a problem ever again), that I can channel the spirit of these students and make the experience positive and fruitful.

There were so many other experiences this week that have moved me and will stay with me forever, but one unifying theme for this week is that I have never felt more present with what I am doing in the moment than I do here. These past three and a half years have been full of amazing opportunities, but there is always something else going on in the background when we’re in Nashville, TN, whether that’s research projects, administrative obligations, studying for the next standardized test, or anticipating what will go wrong in the big case you’ve been assigned to tomorrow. I am thankful for this opportunity to completely embrace a new environment and healthcare system and to devote my time to the seamless exchange of knowledge that seems to occur so naturally here. Can’t wait to see what the next 3 weeks hold! For now, it’s time to take a break and explore Nairobi National Park and Crescent Island this weekend!

Blog Two
It’s hard to believe we are nearing the end of our time here in Kijabe. Over the past three and a half weeks, Olivia, Alex, and I have grown in so many ways. Our eyes have been opened to the inequities of anesthetic care in this part of the world and some of the ways that practice is modified in these settings to optimize patient safety. And we’ve seen first-hand the impact that education in the practice of anesthesia can have, by not only allowing patients to undergo the surgeries they need, but to get them through those surgeries more safely than if they were not being cared for by an anesthetic specialist. We’ve also learned to be better teachers and consultants—a much different dynamic than our role as in-room providers and learners in our program at Vanderbilt. And finally, our tiny house overlooking the Great Rift Valley has become a home—we’re looking forward to having our first dinner guests, Rebecca and Eunice (Kijabe’s anesthesia residents!) over tonight for pasta!

This week, I had the opportunity to experience two days in the intensive care and step-down units here at AIC Kijabe Hospital. Other than knowing it would be extremely different from my ICU experience at Vanderbilt, I had no idea what to expect going in. One of the first things I noticed after stepping into the five-bed unit was a huge window behind the nursing station pouring natural light into the open room and through which the beautiful songs of some of the hundreds of species of birds that exist here could be heard. Shortly after wondering if this potentially had any positive impact on their rates of ICU delirium, at least four distinct alarms began to sound—a monitor alarming for hypertension and multiple ventilators of different types alarming for low FiO2 (sometimes there are problems with the hospital’s pipeline oxygen pressure), another for high peak pressures as a patient’s endotracheal tube was being suctioned while he was not on any sedative infusion (just intermittent morphine and midazolam here!), and a third for low tidal volumes for a patient on a spontaneous breathing trial. Yep—still in an ICU…just with a nice window!

Rounds were being led by a med-peds physician completing his ICU fellowship at the University of Pittsburgh. He had formerly completed 5 years as an internal medicine hospitalist here and now was back for a long-term stint as a portion of his fellowship training. The first patient we rounded on was an 18-year-old with acute hepatic failure, presumably due to autoimmune hepatitis (but we were also ruling out Yellow Fever as an etiology). The ECCO (similar to an advanced practice provider) presented the patient, and the team came up with a plan to broaden antibiotic coverage to manage her septic shock, perform a spontaneous awakening trial, and administer Vitamin K to correct her coagulopathy. We moved on to a trauma patient with a hemothorax, severe TBI, multiple long bone fractures, and rhabdomyolysis, and adjusted his sedation, initiated DVT prophylaxis and tube feeds, and reached out to general surgery due to concern for a retained hemothorax. Next up was a young man who had developed aspiration pneumonia after a bowel resection—we needed to speak with his family regarding plan for tracheostomy, as this was day 11 of intubation and he had failed extubation once already. Next was a young woman with DKA. I was surprised to hear that there was not a chemistry panel since her admission 36 hours prior—how would we know when her anion gap had closed? Turns out, most of the time DKA resolves just as quickly when guided by clinical signs of improvement in tachypnea, nausea and vomiting, and return of appetite—these were our objective trends, along with Q4 hour glucose checks to titrate her insulin infusion. She was transitioned to subcutaneous insulin and was able to move to the general floor later that day. On the step-down side, we saw patients with heart failure exacerbations, panhypopituitarism, and even pulmonary embolism with right heart strain that had to be managed with intermittent IV doses of heparin and a norepinephrine infusion. I was so amazed by the spectrum of pathology this team was managing and learned so much!

The students and ECCOs gave such thorough presentations and proposed excellent plans, and there was so much teaching occurring with every patient we saw. So many aspects of each patient’s care were managed differently here, but that’s what is so cool about the art of critical care and anesthesia—there is never just one way of doing something. My two days in the ICU really summed up the themes of this month for me—it is still possible to provide excellent care with fewer resources. Even though it’s not the ideal situation, the providers here are so incredibly talented, innovative, and compassionate. I’m so inspired by them and thankful for all that they have taught me.