May 14, 2019

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.

Week 1
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.

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.

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.

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.

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.

Week 2
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.

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.

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.

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.