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
Day One: We landed in Nairobi early Tuesday morning after a very long travel adventure that included having our luggage lost and an unexpected night in Amsterdam waiting for it to catch up to us. At the airport the customs and entry processes were very efficient and fast and before we knew it we were loading our things in a van and were off. Matt Kynes and Claire met us at the airport with our driver, Phillip, and it was very comforting to see familiar faces. We headed to a mall in Nairobi to buy groceries. At this point Lauren and I were both starting to feel the severity of our jet lag. We did our best to grocery shop for a couple of weeks but the food selection is certainly nothing like what we find in America! We settled on the basics and are essentially praying we can just survive since we have no idea what to expect. We FINALLY reached our house, which was quite a shock to me walking in. I don’t think it had hit me just how basic life was going to be here until I was putting the groceries away and Matt was explaining how to purify our water and wash our vegetables. Don’t get me wrong, the place isn’t bad but it is lacking a lot of comforts. That feeling of “what did I get myself into?” combined with sleep deprivation and jet lag was quite overwhelming to say the least.
Ultimately, on that first day I felt overwhelmed. Overwhelmed by the unknown, by the responsibility to provide good care to the people of Kijabe, by the homesickness I could already feel, and by the solitariness that I think comes with taking chances like this. At the same time, I also just feel thankful that I have Lauren here with me; she could tell I was having a hard time today and did her best to cheer me up and I need her to be here with me to push me and to keep going in this adventure.
Week One: The past few days have been quite a culture shock both professionally and personally.
First off, on day two (first morning waking up in Kijabe) we awoke to find that we had no hot water and barely any water pressure, so poor Lauren suffered through a freezing cold, trickling shower and I hiked up to the Kynes’ house to shower very quickly before we were due at the hospital. Once at the hospital we met Claire and Ansley as well as Matt and were filmed in various settings throughout the hospital as we toured and were oriented. After a quick PB&J sandwich at home, we both took naps, after which we felt like new humans. We planned our next weekend trip to Lake Nakuru and had our orientation with Ann Rita who is super nice, then our filming continued by going to the Duka and market which were both pleasant surprises by the variety and quality of goods available. After we finished filming we went to the Kynes’ for dinner from Mama Chikus (local restaurant with authentic Kenyan dishes), showered at their house, then came back and essentially went to bed. Needless to say it was an exhausting day and the feeling of being overwhelmed continued to persist.
The following day was better after a good night’s rest. We discovered that our hot water worked! Once at the hospital it was essentially trial by fire. I jumped in with a KRNA (Royaus) and our first case was a lady with a pretty severe lip laceration extending into her nasal passage, we did an RSI and the KRNA got the airway with a bougie but the bougie was in his bag because he keeps his own personal bougie for difficult airways. I then was called to another room for a difficult airway in a child with severe neck burns that had turned into the worst contractures I’ve ever seen that had literally pulled his lower lip and mandible down to his chin. Our plan was an asleep intubation with a glidescope. The patient turned into a difficult mask to the point that we desated to the 60s before Dr. Barnette shoved the ETT into the nose and positioned it just before the cords and we hooked the circuit to it and ventilated. Once the patient recovered we used a glidescope to intubate the patient. The second case I was involved in was back in Royaus’s room and it was a case of the worst fibrodysplasia I’ve ever seen to the point that the patient’s airway was completely occluded and had subsequently been trached previously and was blind. At the point I got involved, the patient had lost approximately 800ml of blood and they had just begun so they were waiting on blood to arrive from the blood bank (the patient had 3 donors from the previous day) so that we could transfuse and they could continue. We ended up transfusing 2 units of blood, giving TXA, and 1L fluid and the patient did fine but the feeling of being in charge in a very foreign environment with a critical patient was quite scary.
So far everyday has been better than the day before. At the hospital we are becoming more comfortable in our role as supervisors and helping the KRNAs and students to provide better anesthesia and becoming more familiar with what the hospital can offer. Taking care of patients with debilitating problems you would never see in America and seeing how grateful and appreciative they are is really refreshing.
Over the weekend we were able to take some hikes, see beautiful views, and encounter some monkeys both on the trails and on our porch. We are also taking advantage of the simple pleasures here like M&Ms, Snickers, and Coke Zero that we found at the Duka (convenience store), which is helping to sooth our homesickness.
Week 2
It is the beginning of week three and the homesickness is starting to set in. I miss my dog, my family and friends, as well as just the convenience of being able to jump in my car and go to the store or to a restaurant. The days at the hospital have been quite long. We have been staying until 5 pm most days as well as lecturing in the mornings. I’ve really enjoyed giving the lectures because we have had the chance to get to know the students a little better and it makes teaching in the OR easier. The students are very hungry for knowledge which I find very refreshing and it has stimulated my own motivation to read more. The challenging and frustrating part of lecturing is most of the material in Morgan and Mikhail isn’t relevant to their low-income setting. So when giving the transfusion lecture we discussed blood components separately, but I’ve only seen whole blood transfused here because that’s all they have available. In the OR, the days vary from being really stimulating and enjoyable to very slow and feeling like I’m constantly wondering around looking for something to do. I’ve found that I mostly enjoy days when I have a case or room to focus on with difficult cases, whether that be comorbidities, interesting pathology, or difficult airways. The KRNAs are very excited for us to do regional blocks on patients and are also eager to learn themselves. This has been really nice for us to help with because it has allowed us to practice what we’ve learned from our regional rotations and see the results, which have been very positive. It is so gratifying placing a block by yourself and then seeing the patient in the OR with only nasal cannula on because your block was successful.
Outside of the hospital, I am getting better accustomed to the “simple life.” Lauren and I make dinner most nights and I must say most of our meals have been quite tasty. We’ve also been back to Mama Chikus, but it wasn’t as good as the first time. After dinner we typically will try to watch a movie or read, either for pleasure or preparing for an upcoming lecture. Last weekend, we had the opportunity to get into some luxury; we took an excursion to Lake Nakuru and stayed in a resort for two nights inside Lake Nakuru National Park. The property was absolutely breathtaking and we were met with warm wash cloths and freshly squeezed mango juice to freshen up after the dusty 2.5 hour long trip. We went on a game drive into the park on Saturday and saw some amazing wildlife including rhinos, giraffes, zebra, water buffalo, hyena, gazelles, and plenty more that I’m sure I’ve forgotten. Back at the hotel we also treated ourselves to massages and a delicious dinner. It was a really nice way to unwind and refresh.
Week 3
Week four, the final countdown! I am very ready to go home at this point. I wish that the rotation was still three weeks because I think the end of last week was the perfect amount of time. I am just ready to get back to my regular routine. Last week we did some interesting cases and there were some really sick people to take care of. One person in particular stands out, he was a 20-something male who sustained a motor vehicle accident and had known bilateral pulmonary contusions and rib fractures coming to theatre for acetabular fracture. We learned of him early in the morning and Lauren and I both went to see him along with the student KRNA. He was on 4L NC in the low 90s, but didn’t appear to have increased work of breathing, lying flat with a C-collar on so we felt it was appropriate to proceed. We had discussed with the surgical team that he would likely need an ICU bed following surgery as he might be challenging to intubate. The patient ended up being a very challenging airway due to his potential for C-spine injury and he was also difficult to oxygenate once intubated, only reaching a SpO2 of low 90s throughout the case on 100% FiO2 and PEEP of 12. ortunately, likely because of his youth, he was otherwise hemodynamically stable and the surgery was done in an efficient manner. We decided that it would be best to leave him intubated and transport to ICU where he could be extubated there. The case finally finished at 8pm and we physically ran the patient to the ICU because we had no PEEP valve available and we were fearful that once taken off our ventilator he would desaturate rapidly. We also only had an SpO2 monitor for transport because that was all that was available, certainly not the way things are done at Vanderbilt.
Over the last weekend we also had the amazing opportunity to go to the Masai Mara. We stayed at the Fairmont which is a luxury resort where you essentially “glamp” in really nice tents with large comfortable beds and an outdoor shower with very, very hot water and outstanding water pressure. It’s humbling how thankful I’ve become for simple things like that. There were four game drives included in the stay and the sights we saw were absolutely breathtaking and incredible. A few of the highlights include seeing two male cheetahs eating a tempi; a male lion and lioness dragging a zebra kill into the bush; a leopard lounging in a tree; an elephant and her baby eating; two rhinos; three lion cubs playing and lots of lions sleeping. It was fascinating how the animals were completely unbothered by our presence and would get surprisingly close to the vehicle. The resort overlooked the Mara River, where there were 30 hippos that spent the afternoons in the river bathing. Then at night they would migrate down the river just beyond our tents, get out of the river and go to the plains to graze at night until around 5am when they would make their way back to the river. The funny thing was they made a lot of noise on their way back into the river and they sounded like a deep evil laugh just outside our tent. On the second night we also had the “pleasure” of hearing a bush baby all night; it makes a terrible pecking noise followed by a series of screams that literally sounds like it’s dying. Between the hippos and bush babies we determined that although the Fairmont was a very relaxing escape from Kijabe, it isn’t a place one should go to get peaceful sleep.
Week 4
As this month comes to an end, I am trying to reflect on the experience and what influence I may have had on others, as well as how this experience has changed me. I think it’s easiest to break it down into categories to really get a good understanding but knowing that all of them blend together.
Professionally, I think this experience has been both really beneficial from some clinical aspects, but also very challenging in others. By helping out here I have had the opportunity to see some incredibly challenging airways due to very unique or advanced pathologies that we don’t see in the US.
Two cases stick out specifically in my head. The first was an extremely cachectic man suffering from a very advanced squamous cell carcinoma of his posterior tongue that presented for PEG tube placement prior to starting chemo/radiation therapy. He was brought to theatre and initially the decision was made to do a modified awake intubation with good localization and ketamine then DL or glidescope. Unfortunately, with manipulation of the airway he began to bleed as well as have increased swelling. Multiple attempts were made at intubation but were all unsuccessful. So the decision was made to abort the procedure that day, wake the patient up, give steroids for airway edema and attempt an awake fiberoptic the following day. When he re-presented to the theatre, we were prepared for awake nasal fiberoptic which went smoothly. I was able to get the scope into the trachea, however, when we advanced the tube the fiberoptic was pulled out of the trachea due to the inability to pass the ETT. At one point we had even lost an ETT in the posterior pharynx which I have never heard of happening. Eventually we were able to stabilize his airway and he got his PEG tube along with a tracheostomy. While it was an excellent learning experience for me, I felt like a very serious palliative care conversation should have been had with this patient because, given his very poor state of malnutrition and the fact that his tumor was unresectable, I’m not sure going through all that he went through was beneficial given he will likely not tolerate chemo/radiation.
The second case is a child with a rhabdosarcoma of his tongue that was presenting for resection. Again, a nasal intubation was planned with glidescope however we found that the glidescope handle was too large to fit the McGills in the back of the mouth and visualize and manipulate the ETT too. We switched to DL but with the insertion of the blade the friable tissue from the tumor began to bleed making the airway very bloody. The patient began to have brisk bleeding and impressive bloody emesis so nasal intubation was aborted and essentially with blind insertion of a bougie and oral ETT was established. The surgeon eventually was able to visualize and stop the bleeding from the tumor and place a nasal ETT.
This rotation has also allowed me to practice my regional skills, especially upper extremity blocks in a way that I think is hard to do at Vanderbilt. Here I’ve been able to use my own judgement about where the best view is and how much local to put where and then evaluate whether or not my block is working without an attending standing over my shoulder dictating exactly where my needle tip should be in their opinion, which has given me a lot of confidence about my ability to perform regional as an attending.
In addition to challenging airways and regional anesthesia, there are also challenging decisions that must be made in regard to resource allocation and realistic outcomes. We had a 20-something year old patient transferred from an outside facility for appendiceal abscess and sepsis that had progressed to severe necrotizing fasciitis extending from his knee up into his retroperitoneum. The surgeons brought him to the theatre for debridement and he was hemodynamically stable throughout the procedure. However, the following day he ended up maxed out on norepinephrine and dopamine infusions. Given his instability the surgeon came up to examine the wound at bedside and determined that his injury was too extensive. He would need further debridement to survive, but wasn’t really stable enough to travel to theatre and given the spread into his abdominal wall his recovery, would be too challenging. The entire time with that patient in the ICU, I couldn’t help but think how this scenario would have been different at Vanderbilt. If we only had access to vasopressin infusion maybe his hemodynamics may have been better and able to tolerate further debridement.
While the clinical cases have been a really great experience, it has been frustrating at times because I feel like our presence here has been met with some opposition. There are certainly some that are very happy to have us help and make suggestions but there are others who would prefer we stay away and our suggestions are met with a lot of resistance if it is outside the norm of typical practice. This mentality is also reflected in some of the students. Part of me can understand their hesitance to accept us because we are just visitors for a short period of time and with or without us they have to continue to take care of the patients the best way they know how. I think what is frustrating is that it makes our role as residents so ambiguous that often times I feel superfluous.
Personally, this month has been very taxing for me as it is the longest I’ve ever spent away from my family and friends. It’s not just from a physical distance standpoint but also the time difference makes it hard to communicate with them because at times when I am home after work they are typically asleep and visa versa; it feels very isolating. In addition to that, it is the first time I’ve ever been submersed into a different culture, especially one that is so opposite from my lifestyle at home. After the initial culture shock wore off, I was fine and even at times I’ve enjoyed the simplicity and quietness in Kijabe. For the most part, the people in Kijabe are very friendly and welcoming.
All in all, this has truly been an adventure for me and looking back I am very happy that I’ve been given this amazing opportunity to participate. There are many things that I will take back from here and use in my practice as an anesthesiologist in the future as well as a better appreciation for not only the amenities that accompany my lifestyle in the US, but especially the access to top notch healthcare within minutes away.