Week 1
Kenya is absolutely beautiful. I thought hard about how I wanted to start this, first impressions are important. I could have mentioned the grueling journey over fighting weather, mechanical issues and lost baggage. The defining feature of this adventure however, has been the beauty of this country. From the people to the natural environment and better-than-California weather, this is a beautiful place in the world and I feel very lucky to be here.
We've been working closely with the KRNA students but this program has expanded it's reach even further. There are three Ethiopian anesthesia residents as well who don't get as much technical experience at their home institution where there are usually 5+ residents to an OR. So they've come for some months to learn, and we've done some tricky intubations with inline stabilization as well as regional sciatic and femoral blocks. I'm realizing that Dr. Newton will probably have directly influenced a majority of providers in this part of Africa over the coming decades, which is no small feat.
On our second day here we experienced a mass casualty. The road conditions are not ideal and motor accidents are common. A head on collision occurred involving a full bus, and there was an infant mortality. With more than a dozen additional people involved in the accident, the gravity didn’t set in until much later. I had to channel my inner surgical intern to help triage the victims and performed FAST exams. I liked feeling a part of something greater than anesthesia, strange to say but the best I can explain is that I felt more rounded and like a doctor treating the people in the casualty ward.
The food got old quickly, generic starch and bland sauce, but it made me appreciate things like Dr. Newton having us for supper. The view from his house was spectacular and his family was very warm and welcoming.
Week 2
We started this week off on an adventurous foot. Utilizing our Sunday to its fullest we took advantage of our only day that all three of us are off work. We met up with a pediatric anesthesiologist who had just arrived from South Africa to do sim lab teaching as part of a week long course alongside Dr. Newton. Together the four of us hired a cab and sped down the rough mountainside road to the Oloongonot Crater. Geographically, Kijabe sits on a mountain on the east side of a feature called the Great Rift Valley. This rift extends from here in Kenya all the way to Jordan in the Middle East. It is the point of separation of two large tectonic plates moving away from each other at a quarter inch a year. The earth's crust is thinnest here and there is a lot of geothermal activity, and many features are possible because of this. Oloongonot Crater is the remnant of a volcanic eruption resulting in the top being blown off and leaving a very prominent crater. We spent a good part of the day hiking the 7km rim in no shade and in some very steep terrain. Looking into the crater hundreds of feet below our soujorn along the rim, there is a very dense, untouched and mature forest. Truly a lost world. The park rangers venture down the steep rim wall, and some guides can take you, but it is very removed from man's influence. What a unique ecosystem it must be.
Back at work this week, things are starting to move. We've been active lecturing the juniors and honestly it's been a blast. The senior KRNA students have returned and I'm meeting them for the first time, as up to this point we have been teaching the two-week-old junior KRNAs and Ethiopian guest residents. They're back for their clinical assessments, a stressful time for them, as they must pass three components to continue to advance and graduate in the coming months; a perioperative evaluation, spinal anesthetic, and general anesthetic. Our role in this is significant as relatively impartial observers, allowing staff and people like Dr. Newton to maintain positions of positive influence. It has fallen on us to deal out the hard knocks when it comes to students who don't score well on each of the 100 point assessments. Several have failed as of the first week and will have to try again. This quality control and encouragement to improve on deficits is invaluable before they are released into the world, representing Kijabe and Dr. Newton's efforts. It is challenging to be an evaluator because feelings can be hurt as one of my coresidents here experienced.
I took my first ICU call which was thankfully uneventful. The amount of information that we take for granted in the States, from labs and exams to medical records and detailed histories is nearly non existent here. When learning about the patients pre-call there was a new gentlemen who arrived today from an outside hospital. He came with a single chest x-ray and a one line history of ‘1/7 days short of breath.’ I assisted intubating him as he was saturating in the 60s, altered and tachycardic. His x-ray showed bilateral pulmonary infiltrates in an unusual pattern and a deviated trachea, but no pneumothorax or trauma history. We are repeating the imaging after intubation and getting labs, and I'm eager to see what we learn. Talking with the ICU team it isn't uncommon to have diseases related to HIV. It also isn't uncommon to never get the answers you're hoping for here. Time will tell and I'll continue to follow.
There have been some very hard situations here. I don't care to go into detail on a public forum, but I know that I'm an emotional person who can get worked up and choked up. It is a challenge to me. To accept things, to accept limitations. To accept families willingness to take those limitations, things that we aren't used to being told in the US healthcare system. I love it here. I hope I can find ways back and that the hustle of the working world I'm about to enter doesn't consume me.
Week 3
I took call this final weekend here a bit different than the weekday backup calls I already covered. It was something I had been ruminating about in anticipation. I had heard experiences from Dr. Kynes and others and had been trying to mentally prepare for the difficult situations that I would encounter. We don't appreciate our resources in the United States. We just don't. Our healthcare is so exorbitant and wasteful. One of the ICU patients passed away. It hit me. He wouldn't have been a case of exorbitance, he just didn't have access to dialysis. In the US he would have had a good chance of surviving his sepsis and renal failure. Here, we could do nothing but wait. I got called in the middle of the night that he arrested, I wasn't able to fall back asleep. That's the first time I haven't been able to sleep while on call. I'll remember it.
Despite feeling powerless to help that gentleman I did find my silver lining as I tend to. My time on call was best spent consoling a family about their elderly mother. Kenyan culture does not like to talk about death, goals of care, or even using medicine for comfort care. In fact, one of my colleagues in the casualty ward (ED) told me his residents refuse to pronounce time of death. Unlike the US, they are also very reticent to use morphine, the most common opiate here, because they think it will kill them. Though that might sound commendable to us it turns it to be very deleterious as patients don't ask for, and nurses need to be coaxed to give, morphine to achieve adequate pain control. In my situation an octogenarian had undergone major abdominal surgery and returned shortly thereafter with wound dehiscence, sepsis and multiorgan failure. No surgical interventions were offered and she was deteriorating. I spent most of my morning speaking with her family about the situation and the direction it was heading despite our medical treatments We discussed comfort care and goals of care, it was a lot but they had great questions and were responsive throughout the discussion. I really hope it helped them. She passed two days later.
Our assessment clinical exams of the senior KRNA students continues daily. The spectrum of abilities and medical knowledge amongst them is staggering. Several I would trust to taking care of my own mother, others are genuinely not safe to leave alone at all. The biggest difference is really in the depth of understanding. Maybe it's the educational system here, maybe this is why we are here to teach and help them understand conceptually… But many of them can't explain when you ask them ‘why’ and ‘how.’ They will just spit back buzzwords that they know are related to the topic because they've made an association. It's alarming to me, but that's the point of our assessments, we are trying to establish some quality control. A KRNA (not from Kijabe) at a local village in the valley recently gave 2g tranexamic acid in a spinal for a cesaerean section, the patient started having seizures and became unstable. Yes there was a drug error, but there was also very little management of the complication. No thinking on the feet. She ended up arresting. Training people to think and problem solve, how to behave in emergencies and troubleshoot is what makes us better than robotic drug delivery systems. I hope that our efforts here are raising the bar for this standard of comprehension.
Dr. Newton took us to meet his friend Simon one day. Simon is a pastor for the Masai tribe in the rift valley. They have been downtrodden for a very long time and Simon is enacting change. Starting with classes held under a tree by his church some 25 years ago, he has now built multiple schools with near two thousand students having passed through. His efforts to give his people an education are commendable, but he does even more. Their culture traditionally does not treat women equally. Female circumcision is a problem he's fighting against. Rape and abuse are commonplace with no repercussions, so he actively speaks out and teaches against this as well. He has even opened his home for girls to have sanctuary; girls as young as 14 who are sold for marriage who run away and have no where. Despite the social issues that come from a long deeply ingrained history, the Masai live and make strides. Their home in the valley is largely inhospitable, think west Texas as Dr. Newton says. Resources are limited. Ways to survive are limited. One of the village ladies drives her donkeys to town to bring water, a day long journey that makes her maybe 4USD a day. Arduous. It seems like a fragile balance from the outside. Couple this with the social tensions between local Somali camel herders, and their history of going to war with the Kikuyu people up the mountain where we are, as well as the wildlife capable of killing men (there's a python story) and these people have a harsh existence.
As the final week winds down you realize just how much you'll miss it here, I have never had such a view while studying. I think it's largely due to how welcoming everybody here is. They make you feel like you belong, treat you like family. So many kind and enthusiastic people that become your world while you're here. In such a short time several dozen people are familiar and integral to me, my daily routine and my social life. This last week feels borderline lavish with the celebrity we've received. Majority of the nights have been invited out to eat at colleagues houses. It's really an honor, and the cooking has been most excellent, Cameroonian has some wonderful heat!