June 17, 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 arrived at the Kijabe hospital campus on a chilly Sunday afternoon. Helen from the housing department came to greet me and showed me to my dormitory, which will be my home over the next three weeks. She gave me a short tour of the hospital and cafeteria, then handed me the keys to my room and wished me luck.

Later that day, I met up with another Vanderbilt fellow, Eugene, who had already arrived and had been working at Kijabe hospital for a week. We walked around the campus grounds and made a short trip to one of the small shops for some food items. On my return the dorm, I met some of my roommates: Kat, an American medical student at Kijabe hospital for early clinical experience and a research project; Jennifer, a pastor in training who will be at Kijabe for a six month rotation; and Amy, a native Kenyan in her first year at Kijabe for training in Family Medicine. So far, we have all gotten along well.

I was a little nervous my first day in the ORs at Kijabe hospital. Thankfully, Eugene was a familiar face in the morning and helped introduce me to some of the KRNAs and a pediatric anesthesiology fellow from Uganda namedFrances. I hung around OR 5, which is typically designated the pediatric OR, and assisted in inductions, intubations, and emergences of the pediatric general surgery cases. I worked with Teddy, one of the newly graduated KRNAs, who told me he had an interest in pediatric anesthesia and we talked a little about extubation criteria in infants and children. 

Later Monday evening, Eugene and I went to the Dessert Night, where we were able to meet some more folks from all over who had come to Kijabe hospital. Tom was a UK medical student in his fourth year doing a couple of elective rotations in casualty and surgery; Josh is an ENT surgeon who arrived at Kijabe a month ago, and will be here for two years. I was fortunate to meet many other great people that night. I met a palliative care physician from Wisconsin, a pathologist from Texas, an orthopedic surgeon from South Carolina, and a general surgeon from Texas. It was great to meet so many people who are helping to contribute to the training of Kenyan physicians, surgeons, and nurses.

Tuesday was a bit of an exciting day in the pediatric ENT room. I found myself working with Josh, whom I had just met at Dessert Night. Unfortunately, I had to delay his first case as the patient had sickle cell disease, a hemoglobin of 8, no IV fluids - so likely dehydrated - and an SpO2 of 93 percent on room air. I wanted to make sure that we had blood available in case of bleeding (he was having a T&A) or a sickle cell crisis due to stress from surgery or hypoxemia. So we decided to proceed with the second scheduled case first which was a healthy two-year-old female presenting for T&A due to OSA. Her mother reported a mild cough, but said she had a chest x-ray at an outside hospital, which she said was clear. Upon evaluation of her lung fields, her breath sounds were clear and her heart was RRR. Her surgery was relatively uneventful, however, she did produce copious secretions during emergence, requiring suctioning of her oropharynx and down the ETT. 

After meeting extubation criteria we took her to the PACU where she began to display signs of emergence delirium and was trashing around in the gurney. Afraid that she may hurt herself, the KRNA student and I decided to give her a dose of Ketamine (dexmetatomidine is not available due to price). Once the child calmed, we began to place monitors, however, I noticed that the child was no longer breathing. I tried to stimulate the patient but still no response. I quickly began chest compressions and told the KRNA student to get an AMBU bag and call for help. Once help and the ambubag arrived I began giving rescue breaths and one of the KRNAs took over chest compressions and pulse checking. My assumption was that the patient had laryngospasm and when I took a look with the laryngoscope as the nurses were drawing up succinylcholine, I was correct. Her vocal cords where completely shut and I could not pass the ETT.  We gave a dose of succinylcholine and I was then able to take another look and successfully place the ETT.  We had ROSC shortly after starting chest compressions and we were able to extubate her about an hour after initiation of the code in the PACU. It was my first time running a real-life pediatric code and though it was extremely terrifying, I was proud of myself for reacting quickly, maintaining my composure and, of course, successfully resuscitating the child. 

Later that same day, our sickle cell patient was brought back to the OR for his T&A after adequate fluid resuscitation and blood availability. The surgeon had some significant bleeding intraoperatively, and his post-op hemoglobin was 6.7 g/dL. He was transfused in the PACU and tolerated it well. At the end of the day, I was happy with my clinical decision-making and that all my patients made it out of the PACU alive!

Wednesday, I was able to work in the neurosurgery room where we started the day with a myelomeningocele in a three day old, who had delayed emergence likely secondary to hypothermia despite our best efforts to keep him warm. Then followed with four pediatric VP shunts for hydrocephalus. I could not believe my eyes the head size of these children.  I have never seen a hydrocephalus in the USA like the ones I saw at Kijabe. Our final patient’s head was so large, that I had to step in to intubate as the positioning was so challenging, it was making visualization of the larynx and glottis difficult for the KRNA student. 

Speaking of difficult intubations, I was asked to go to OR 3 to assist with a potential difficult airway. When I arrived, I saw a man whose lower jaw had been removed due to tumor, and needed a follow-up surgery as the metal bar that had been placed after his initial surgery became dislodged and need to be removed and replaced. I felt that this patient would likely not be a straightforward direct laryngoscopy intubation, so I opted for an awake-sedated intubation. We anesthetized his glossopharyngeal and superior laryngeal nerves with atomized lidocaine, and I performed a trans-tracheal block of the recurrent laryngeal nerve with 3 mL of 2 percent lidocaine. He was given IV glycopyrrolate prior to anesthetizing the airway, then 50mg of ketamine for sedation after adequate topicalization. One of the KRNAs wanted to take a look with DL first to assess the difficulty of the airway. The patient tolerated the DL well, however, the KRNA was unable to appreciate any recognizable structures. I stepped in with the video laryngoscope and was able to achieve a grade 1 view of the airway, and he was successfully intubated. The patient tolerated the intubation well and the ETT was secured with suture by the ENT surgery team. He was later extubated fully awake and had an uneventful recovery in PACU.

After work, I headed home to my dorm and began packing for our trip to Mombasa for the 7th Annual KRNA Education Conference. 

Dr. Newton, Eugene, and I arrived in Mombasa on Thursday morning and made our way to the Severin Sea Lodge, where the conference was being hosted. It was a fantastic experience to meet so many of the KRNAs that had been trained at Kijabe and to learn where they were working now and what kind of resources they have available to them. There were over 100 nurse anesthetists at the conference with three East African countries represented: Kenya, Ethiopia, and South Sudan. I gave two pediatric anesthesia lectures, one on perioperative management of bowel obstruction and the second on transfusion therapy, as well as a workshop on EKGs. It was such a wonderful opportunity and I am so thankful that I was able to be a part of the continuing education of nurse anesthetists in Africa. 

We arrived back in Kijabe Saturday night and Eugene and I made plans to hike Mount Longonot Sunday morning.  One of Eugene’s roommates, an orthopedic resident from South Sudan joined us for the 13.5 km trek up and around the rim of the volcano.  The area was so green and lush and we were even able to see some zebra and antelope off in the distance. Unfortunately, visibility was pretty low due to fog so we were not able to see the entire crater floor. It was a difficult hike to the summit at times due to steep sections of the rim, but we endured the elevation gain and had some pretty amazing views of the valley below. 

Now it is time for me to wrap-up my first week and prepare for my second one here at Kijabe. 

Week 2
This was an intense week both physically and mentally. Physically tough in terms of the amount of hours worked. I spent a majority of the days in the operating rooms, often staying past 6 pm to help place an epidural or nerve block, wake up a small infant, or deal with crises in the recovery unit. It was mentally difficult in that I experienced my first intraoperative death. 

My years of being a student athlete at the collegiate level and my time in medical training have prepared me well to deal with long work hours or a physically demanding schedule. Though it is not always easy, it is something that I have grown accustomed to.  Although I have dealt with adversity and failure in sports, life, and medicine, it has never been at the expense of a patient’s life in the operating room. I have witnessed patients dying in the ICU and have been a part of code situations on the floor in which the patient did not survive. However, this was different. 

This patient was in septic shock and dying in front of our eyes. She had altered mental status, her pulse was thready at best, we could not get a blood pressure or pulse oximeter reading, and her extremities were ice cold. After she coded the first time with us, we began running a high dose epinephrine drip just to maintain a carotid pulse. By the end of the surgery, she was on high dose epinephrine and norepinephrine infusions, and had received multiple code doses of epinephrine along with large calcium and sodium bicarbonate boluses. When we removed the protective tape from her eyes, we noticed her pupils were fixed and dilated, she was not making any respiratory effort despite no anesthesia, and she continued to go into abnormal heart rhythms (junctional, bundle branch block, bradycardia).  The decision was made to discontinue resuscitation measures and turn off the ventilator.

One of the things that I love about anesthesia is that you can devote so much of your time and attention to a single patient. You are trusted to take care of that patient and keep them safe. But sometimes, despite our best efforts, the outcome is not what we had hoped for. When an adverse event occurs to one of my patients, I like to reflect on the situation to see if there was something that I could have done differently to prevent or treat it, so I can learn for the future. After going through this reflective process with the people involved in this case, as well as with Dr. Newton who was not, I do not think there was anything that we could have done differently that day that would have changed this patient’s outcome. I say this not to make myself feel better, but because I truly believe we did our best with the resources we had available and the condition the patient was in prior to arrival.

Though this was a demanding and exhausting week, I am grateful for the experiences and lessons I have learned.