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.

Week 1&2
“Everything is going to be sawa sawa”

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.  

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.  

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.

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?

Weeks 3&4

“10 Reasons to Love Kenya”

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.
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.  
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.
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.
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.
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.
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?
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.
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.  
10.    Chaptai.  Just to bring this full circle.