Week 1
I would love to say Kijabe went off without a hitch, but one foot of snow in Detroit prevented us from getting off the ground. We spent 3 hours in BNA trying to get on another flight as nothing was going through Detroit that night. Luckily, we hopped on a flight through Atlanta (not messing with the Midwest in mid-February again) the next day. The travel wasn’t as bad as I thought. Although, my first transatlantic flight was grueling. Sitting vertical 1.5 hours between two people was not my best night’s sleep. We landed in Amsterdam in the morning. After a lazy layover with coffee and some Olympics, we hopped on our next 8 hour flight to Kenya. This one was much smoother, probably because I slept through half of it. Upon our arrival, we awkwardly went through customs, picked up some shillings and found our driver. That night we slept in a resort that was beautiful. We had a separate room, clean sheets, bathroom, and delicious breakfast in the AM. However, my shower was freezing cold because I hadn’t learned Kenya’s hot water heaters have an on/off switch outside the bathroom. Lesson learned. After breakfast, it was a short ride to Kijabe arriving a day later than expected. We started our trip with our first of many stops at the Super Duka to pick up some snacks and essentials. Everything is super cheap here, and it took some getting used to the exchange rate. Next, it was on to our house where we met Helen who gave us the grand tour. The house is cozy with a living room, warm colored pillows that match sunset orange curtains. The living room flows into a dining room where we would spend many dinners and nights studying. A turn to the right leads to the kitchen equipped with a microwave, coffee pot, water filter (essential), and refrigerator. Various spices, sauces and other cooking additives had been left by previous guests. Past the kitchen was a hall where our bedrooms and 1.25 working bathrooms lived. There will be more on that later. After depositing our luggage, we changed into scrubs and were escorted to the hospital by Helen to meet Mark and the rest of the OR staff. Day one was all orientation, saving the work for later in the week.
The theme of days two and three was assessments. Many of the senior KRNA students were reaching the end of their training. This meant final exams. Each KRNA student had to prove competence and proficiency performing a preoperative assessment, spinal anesthesia case, and general anesthesia case. It was our job to offer a second opinion to the KRNAs on whether that student should pass that exam portion. This proved more challenging than I thought. The KRNA students vary greatly in their level of training. Most are extremely well read, but many lack the clinical application of knowledge. All would know precise doses (and dose ranges) of induction drugs and would recite them robotically. But, when presented a non-routine case, some were unable to deviate from these facts. When asked about hypovolemic or other challenging patients, many would just regurgitate the textbook answer of induction drugs and not adjust for changes in hemodynamics. When using ketamine to supplement pain, most want to use 1-2 mg/kg, the induction dose. Don’t get me wrong, everyone knows their patients extremely well and most are well read. Also, they work hard, arriving early to meet all of their patients and set up their room. The days are taxing without many breaks, but I’ve never heard one complain.
As expected, most of the tools here are different. They have halothane (although I’ve yet to use it) and sodium thiopental. All of their equipment is sterilized and reused including suction tips, laryngoscope blades, stylets, oral/nasal airways and others. They all share medications out of one big syringe that is drawn off for each case. Vasopressor options are Epi, ephedrine, glycopyrrolate, and atropine. Occasionally, the student can run to a secret place and find phenylephrine, but this is usually restricted. That was a surprise when I had an elective cesarean patient under spinal have refractory hypotension despite ephedrine boluses. We found the secret phenylephrine and saved the day with just 200 mcgs. It’s weird teaching medications, including medications we don’t use (halothane and sodium thiopental). It’s certainly challenged me to go home and read every night. Good thing I brought Morgan, Mikhail and Pocket Anesthesia with me (PS-pocket anesthesia is super popular here). Many KRNAs and KRNA students have asked for my copy. I’ve asked Grace to see if we can round a few up to send to Kijabe in the near future as they would be a great intraoperative resource.
Outside the OR, Alex and I have done quite a bit of exploring. We’ve tried to run almost every day, but the altitude and hills have been quite humbling. They are getting easier, however, and it should provide great marathon training for when I get back to Nashville. Tonight was our first meal at Mama Chikus. The food was outstanding and the whole thing was only $3.10! We’ll definitely be frequent customers while here. Today, was also my first day covering the ICU. These patients are sick. I had no idea. We started the day accepting a trauma patient who had just arrested in the step down unit from likely blood loss and hypovolemia. After 30 minutes of CPR and 5 mg epinephrine, they got ROSC, so he was sent to the ICU. Upon arrival, his presenting ABG was 6.9/18/173/-26 on the ventilator. A bedside TTE showed a completely collapsible and hyperdynamic left ventrical. We gave him 4 units of whole blood and started a norepinephrine infusion until we could get more volume in him. We also gave 60 mmol of bicarb and let him blow off his acidosis with a MV of 16-18 on PS. After some volume, he came off the levo drip and remained off all day. Thankfully, he’s planning to return to theater (the OR) tomorrow to fix his leg again, which I suspect is the source of his bleeding. The rest of the unit is an ACDF paraplegic with aspiration pneumonia, SDH s/p evacuation with either SIADH or CSW and Na of 120, MCC with bilateral flail chest, bilateral chest tubes and saturating 94% on NRB. The step down unit is not much better. May be a long night on call tonight. Up early tomorrow to round before Alex and I set out for hiking around the volcano, Mt. Logenot. I’m excited! Pictures to come.
Week 2
Three patients died this week. Three patients died who didn’t have to and likely wouldn’t have in the states. I guess it’s time to blog about our clinical time here. This week has been frustrating for a multitude of reasons. The hospital care is often substandard. The first death occurred when a trauma patient who survived his initial operation well with minimal resuscitation had a hypovolemic arrest in the stepdown unit the morning after surgery. The stepdown unit has 5 beds and a nursing desk packed in a room no bigger than a standard American living room. Someone should have noticed a trend in vitals signifying hypovolemia. The surgeon even commented that he had never seen a patient arrest due to hypovolemia while in a monitored setting. We eventually achieved return of spontaneous circulation during the arrest, but the patient never recovered a good neuro exam and died three days later in the ICU.
Resources are also extremely limited here. The second patient death this week was a little more expected. He was an MVC patient who presented to the OR intubated with a thready pulse and positive FAST exam. Typically, the patient would have an arterial line placed for blood pressure monitoring and large bore IV catheters or a central line for volume resuscitation. The hospital has none. The largest IV cannula is an 18 ga catheter. There are a small number of 16 ga catheters that surgeons and anesthesia faculty have hoarded in their office. In addition, we would typically wait for coolers of blood to be available before opening the patient’s abdomen; however, his blood type, A negative, was unavailable in the hospital. The surgeon asked if anyone in the operating room had A negative blood and even went so far to call people at home. It just so happened that I’m A negative, so I was ushered to the phlebotomy lab. After a few questions, I was donating a unit of blood for the trauma patient. In addition, two of the surgeon’s wives were also A negative. Both dropped what they were doing at home to come donate blood overnight. The generosity was moving seeing the community come together for a patient no one knew. Unfortunately, the patient died before the blood could be donated. At Vanderbilt, with massive transfusion protocol, he likely would have survived. The third patient was from the same accident and died bleeding out from a pelvic fracture. This was also likely preventable, but a result of lack of resources.
In addition, staffing this week has been limited. Now that the end of curriculum assessments are done, many senior KRNA students are no longer there. In addition, some KRNA leadership was out of town teaching students at other clinical sights. Furthermore, the junior KRNA students had exams Thursday and Friday and were also not working. This left significant coverage gaps. So, Alex and I stepped in and staffed a couple of rooms solo. We ended up seeing some pretty cool pathology. This week, my room had a large carotid body tumor and an enormous mandibular osteosarcoma, both of which we resected. In addition, my room next door had an ecclamptic patient rushed to the operating room for an emergent cesarean section. I left the junior in my room and hurried next door to help manage the patient. Alex saw the commotion and was also able to come help. Being the most senior providers in the room for such a critical case was a good pulse check to test our training. We handled the case well, and the patient delivered and recovered in the ICU. Speaking of lack of resources, the end-tidal CO2 monitor was nonfunctional in my room one day, and we could not fix it. After talking with our attending, we proceeded with surgery while the OR staff worked to find a solution. It was fixed not long into the case, but I realized that it was standard for many hospitals in Kenya. End tidal CO2 monitoring, like many other monitors, is a luxury not shared by all anesthetists. Kijabe hospital, one of the best in the country, doesn’t have end tidal agent monitoring, accurate minute ventilation calculation, or support mode ventilation. There are many things we take for granted in the States that many other parts of the world have never seen.
The week wasn’t all negative. These were just a couple of parts of Kenya I hadn’t expected. Alex and I have taught morning lectures all week. Monday and Tuesday we taught junior KRNA students, but Wednesday and Thursday was much more interesting. We presented to the students and KRNAs in Kijabe and were broadcasted to other clinical sites around East Africa. Lastly, we were invited to present at the KRNA chapter meeting on Saturday for senior KRNA leadership from all over Kenya. It was really cool seeing our teaching expand well beyond our small Kijabe hospital to help so many other communities in East Africa.
We also had a few visitors at the house this weekend. A pack of baboons stopped by and two stayed to enjoy the shade under our porch. Luckily, they didn’t cause too much mischief and were out of sight not long after they came. Today, Alex and I ventured to Nairobi National Park to see some big animals with the city skyline in the background. We saw so many animals! - gazelles, impallas, zebras, giraffes, ostriches, water buffalo, hippos, lions and rhinos! There was even a baby rhino with it’s Mom. Can’t wait for our real safari on the Masai Mara next week!
Week 3
Hard to believe our short stay at Kijabe hospital has already come to an end. The third week was by far the best and most diverse. Happily, the KRNA student assessments were all completed, and the theaters (ORs) were fully staffed with KRNAs and KRNA students. This gave us freedom to float between rooms to manage cases and teach many different students. We also gave our last lectures to the junior KRNA students. I’d be lying if I said I wasn’t relieved the lectures were behind us. They took much more effort than either of us had anticipated in advance. Most lectures were prepared and just needed some minor editing/reviewing the night before. Alex and I did prepare a few lectures from scratch, which took a good deal of work. However, as I reflect on the month, I was impressed at the amount I learned from lecturing and teaching. Not only did my depth of understanding on certain topics grow, but my breadth of knowledge also expanded as I discussed new topics with the KRNA students.
There were a couple of gut-check moments this week. My ENT room had another enormous mandibular sarcoma. The airway exam was atrocious. A huge mandibular mass distorted the patients jaw suggesting a quite challenging mask ventilation. There was poor oral opening due to tumor restriction. His lower mouth was full of soft tissue elevation into the oral cavity, and the tumor pushed his tongue to the back-right corner of his mouth. We planned a spontaneously ventilating nasal fiberoptic intubation. Induction proceeded smoothly and I placed the fiberoptic scope, however, he was full of oral secretions despite glycopyrrolate at induction. In addition, his airway was completely distorted. After some manipulation, I found arytenoids and placed the scope above them. The epiglottis and vocal cords were unidentifiable. The endotracheal tube passed easily, and the tumor was resected without issue. At case conclusion, we extubated the patient awake and transported them to PACU. As the student was giving report, I noticed a pool of blood above the patient’s clavicle that tracked down from his lateral incision edge. I held direct pressure, which stopped the bleeding, but I noticed he was becoming more agitated. Not long after, I saw his lower mandible was swelling significantly. We notified the surgeon as I opened the airway to alleviate any obstruction. The surgeon arrived to bedside, quickly diagnosed an expanding hematoma threatening the airway. We rushed the patient back to the OR before it was clean with no OR staff around. I called to one of the KRNAs to bring the glidescope and meet us in the OR. By the time we entered the room, the patient was in significant respiratory distress and was no longer responding appropriately. Initial saturations were 85%. We attempted to place an oral airway and mask to ventilate the patient, but he no longer had a lower jaw to lift or elevate and we were failing. Saturations were falling so we elected to intubate and secure an airway before his oral cavity completely obstructed. Using the glidescope, several hands, and cricoid pressure; we barely gained a grade 2 view on the glidescope screen. Saturations continued to fall to a nadir of 0 as we placed the endotracheal tube. After securing the tube, his saturations rapidly rose to 100%. The patient never became bradycardic and he never lost a pulse. The surgeon opened the sutures, evacuated the hematoma and obtained hemostasis. The patient was transported to the ICU intubated. The next morning, I visited him and was glad to see he had been extubated earlier that morning. Moreover, he was alert and oriented, sitting up in bed and off oxygen. To my surprise, he recognized me and was excited to see me. Through hand gestures and body language he thanked me and appeared very grateful.
The second gut-check moment came when I was supervising a spinal in my room. An OR nurse rushed into our room and asked for help next door. I hurried to the room and found a patient’s HR in the 30s and a barely palpable pulse. She was a 96 yof who was having a foot debridement under spinal anesthesia. She was also obtunded and being mask ventilated. It seemed her high spinal was progressing toward a total spinal. They had already given atropine, and I quickly taught a student how to make baby epinephrine. After atropine and epinephrine and elevating the head, her blood pressure improved and so did her mental status. The case proceeded without further issue, and she recovered well. There’s never a dull moment at Kijabe hospital, and I’m glad to have helped in many ways these past few weeks.
Thursday, it rained for the first time all month, which apparently meant the rainy season started. It came a full month early this year, which was a popular political conversation around the community. Kenya, in response to the rapid climate change, placed a nation-wide ban on logging this week. Many of the communities rely heavily on logging to thrive selling charcoal, so this ban has met some resistance. There were protests scheduled in Nairobi today, making city travel difficult. Luckily, we drove to the Masai Mara today to begin our Safari! Alex and I are ecstatic to explore the Masai Mara. The hotel is incredible. Luxury tents, three course meals, full service, and all surrounded by the African jungle! We have two full days of safari and relaxation to unwind from a busy month. We’re excited for this once-in-a-lifetime opportunity and can’t wait to share photos and stories upon our return!