I am writing this as I lay reclined on a sofa, the same way I have spent many early evenings. The sounds of the Raffi Spotify playlist and my 15-month-old son pulling tupperware from the kitchen cabinets have been replaced with unfamiliar bird calls, crackling fire, and soft rain. Two weeks in Kijabe, Kenya have been illuminating, both in terms of how I view the practice of medicine at home and abroad, and also - more unexpectedly - how I view myself as an Anesthesiologist and a leader.
While Kijabe Hospital is considered to have a high level of resources compared to other rural African hospitals, the differences between their practice environment and ours is stark. Airway and surgical equipment is washed and reused, most classes of medications have only agent available, and patients are brought back to the ORs and left alone until anesthesia and surgical teams arrive.
Not all of the differences favor the West, however. The KRNAs are extremely adept and comfortable with spinal anesthesia, as it makes up a huge portion of the care they provide for a number of different surgeries. This saves the patient both the costs and the risks of general anesthesia and airway manipulation. By all observation, it appears to be extremely well tolerated by most comers. Even without second to second fetal monitoring, emergency Cesarean sections are presented as structured and calm affairs (though rapid and efficient), without the disorganization and hysteria that all of us have seen at times. Opioids are minimized or avoided to an impressive extent, with a combination of regional anesthesia and intravenous acetaminophen and NSAIDs. It is a testament to the safety of our practice in the states that surgery can be performed under such constraints as there are here, and still accomplish fair outcomes.
Perhaps the most enduring lesson I will take from my time here is the feeling of being the last defense between my patient and bad outcomes, with no other backup immediately available. We have come as relative experts in a number of areas, from regional anesthesia to critical care management. When consulted, we are expected to provide the final word on who is appropriate for a block, who is ready to be extubated, and who should not have surgery. This will obviously be the daily expectation of our careers going forward as attending, but it is humbling, stimulating, and at times exhilarating to experience medicine without a safety net for the first time here.