Week 1
We arrived to Kijabe this past Sunday. Jon and I had a long travel day, but we couldn’t say much given that Geoff missed a flight due to a mechanical delay out of Atlanta and was subsequently diverted from Amsterdam through London. This re-route meant he had two consecutive overnight flights. My natural inclination would be to say that no destination was worth the amount of discomfort and sleeplessness that Geoff endured on his way to Kijabe, but after a week in this town at 7,000 feet in equatorial Kenya, I would have to say that whatever you endure on the trip to this place, it’s probably worth it.
From our guest-house in Kijabe, we overlook the Great Rift Valley and have a view of a volcano called Mt. Longonot. In the evenings, you can see the crater at the top of the mountain, and inside of that crater there is supposedly an entire forest. Tomorrow we are set to take a day trip to the base of the mountain, and the plan is to hike to the top and then around the crater. Not a bad way to spend a Sunday. In addition to the spectacular views, the weather here is supreme. There is a constant cool breeze that picks up in the evening and sounds like the waves of the ocean outside our house. The average temperature is probably around 65-72 degrees Farenheit, and most of the time there is not a cloud in the sky. I’ve seen more different types of birds outside our house in the week we’ve been here than I knew existed, plus we often see monkeys when we go on walks around the town. I think if medicine doesn’t work out for me, I could be happy here as a gardener or Jon keeps saying he wouldn’t mind being a professional ornithologist.
While the climate and natural beauty of this place are pretty remarkable, it has been the kindness of the people who live here that has been most astounding. People of all countries and cultures have misconceptions about what people in other lands are like, but at this particular moment in time, our own United States is perhaps most guilty of creating and perpetuating false characterizations of the inhabitants of other countries, especially developing countries. I feel extremely fortunate to be here and see the goodness of the people who live in this town. The days in the operating room have been educational, but I’m already pretty sure that a renewed faith in the underlying compassion and connection between people of all places and races will be the biggest takeaway from this rotation and trip.
Week 2
I was told that 20 years ago when Mark Newton and his family took up permanent residence in Kijabe, there were only two ORs in the hospital. There were surgeons in the area, but without reliable anesthesia they didn’t operate all that much. There is no real question of the ‘chicken and the egg’ with surgery and anesthesia. I think it’s safe to say that only butchers and desperate men/women operated before anesthesia. There were no KRNAs in Kijabe when Dr. Newton first arrived. He informally trained a couple of nurses, and eventually he started the KRNA program that we help out with here at Kijabe.
There are currently 15 full-time KRNAs at Kijabe (according to a KRNA I’ve worked a lot with named Luke who is my reference for a great deal of information on Kijabe and the surrounding area). Each class of KRNA students is currently made up of 15 students. The students receive lectures of some sort every morning. The past week, we have assisted with the clinical assessments of senior KRNA students. The assessments are extensive and include a pre-operative assessment and assessments of two cases; one performed under general anesthesia and the other under spinal anesthesia. The pre-operative assessment can last up to an hour, and the ‘spinal’ and ‘general’ assessments last the entirety of a case. An experienced KRNA is paired with a Vanderbilt resident, and together we make sure the senior students can independently deliver safe anesthesia. The experience is intense and nerve-wracking for the students. One KRNA who graduated last April says she was more nervous during her assessment than she was for the birth to her first child. I imagine the experience is some amalgamation of Oral Boards and an intense version of Sim Lab or perhaps the MOCA we all hear so much about. Many students fail at least one of the three assessments, and they have a single second chance to pass or else they have to spend extended time as a student. As assessors, we are encouraged to have no fear of failing the students. It is raw and a pretty honest form of competency-based assessment.
The more time I spend in Medicine, the more I realize that educating clinicians is not easy. I would argue that teaching anesthesia is particularly difficult because it is both procedural and cerebral, fast-moving and demanding of quick decision-making at times but perhaps at its best it is boring when a clinician is always a step ahead of the surgeon, the case and the evolving pathology. All of this to say, I don’t know what the best way is to teach future anesthesia providers. I have enjoyed participating in a different educational model here in Kenya. I enjoy giving lectures to the junior KRNA students and helping with the assessment of the senior KRNA students in a way pretty similar to staying up late into the night helping out a CA1 during their first Level 1. It’s all good stuff. It’s especially good when the people you interact with are hungry for knowledge, and the majority of them want to be really good here just like anesthesia residents and SRNAs back home (if only other professions such as those going into politics could attract such good and well-meaning people).
As week two wraps up, I realize that there are very different considerations and barriers with helping the KRNA students learn compared to medical students or junior residents back home. We are learning what works and what does not. We have learned that the junior KRNA students retain a lot more when you call on them to answer questions, and a PowerPoint is good but interaction is better. We are realizing that sometimes what we might think are basic concepts to us might be difficult for them, and they need to be repeated multiple times. I am realizing that I can be hard for some Kenyans to understand (never thought I had that much of a Southern accent but I guess it’s there). We are learning, we are making progress and we’ll keep trying.
Week 3
Our time in Kijabe has concluded. I’ve eaten my last samosa and piece of chapati for at least the foreseeable future. Being away from my wife and 6-month-old son for three weeks has not been easy. Before finally pulling the trigger on signing up for the rotation, I debated whether going on this trip was the right decision multiple times given that I’d be leaving my wife alone with our son for three weeks. In the end, it was my wife more than anybody who convinced me that despite not being excited about my absence, I should still go because it is an experience that is in line with who we want to be as a family. Even after we made the decision though, it was hard being away from those I care about the most. For this reason, it feels all the more important to reflect on what has been achieved during this trip and what it has meant to be a part of the anesthesia team at Kijabe hospital.
We have seen and performed the anesthesia for a large variety of cases in the eight ORs and one endoscopy suite in the Kijabe hospital this past month. The ORs are busy here. They perform everything from urologic to pediatric to neurosurgical cases, and I would guess the operating theater in Kijabe is on par with some community hospitals in America with the level of immediate perioperative care it provides its patients (I think the ICU and wards lag behind the operating theater here a bit, perhaps because of Dr. Newton’s extensive work in the ORs).
I’ve always enjoyed Pediatric and Obstetric Anesthesia more than other specialties, so perhaps this is just my bias coming out once again, but it feels like these are the two areas where the anesthesia personnel is making the greatest impact at Kijabe. Jon mentioned in his first blog post that during our first week, we took care of two women who experienced cord prolapse and were emergently brought to the operating theater. Neither of them had an IV when they arrived. The second woman had all of the classic features of a difficult obstetric airway. For those outside the anesthesia world, it’s not worth going into the details but trust me when I say this can be a scary patient to take care of. As she rolled into the room, a KRNA got an IV as I drew up drugs and Jon checked the airway equipment. We positioned her as well as we could as the surgeons prepped and draped. I induced, and while the KRNA held cricoid pressure I helped to lift her shoulders up and give her lower neck a little flexion and upper neck a little extension, and then Jon did a great job getting just a good enough view to use the bougie to intubate the trachea and we secured the airway uneventfully. In both cases, baby and mom did great. A week later, a woman survived a significant post-partum hemorrhage that lead to an emergent hysterectomy (and this was the type of hemorrhage that would likely have taken her life in many other parts of Africa and even many places in America). Each Wednesday, we did at least eight cesarean sections and usually many more (and we did many other C-sections scattered throughout the week).
As for pediatric cases, there were at least two ORs dedicated to caring for children every day. I was impressed by the number of kids we took care of with significant myelomeningoceles and hydrocephalus. There were also children with large head and neck masses, burns and many other conditions that no kid deserves. But they all received excellent care at Kijabe.
So in the end, the not-so-surprising conclusion is that it was of course all worth it. It’s also worth mentioning that this is the first medical mission trip where I’m not worried that the people of the town I’m leaving are going to continue to receive great care. They have a system in place at Kijabe. We help out, and I’m proud of our role there, but they know how to care for these folks. That sense of accomplishment without regret or worry makes it all the more exciting to get back to my family.