Call Night

Internal medicine/ICU call has been fun because it has often brought me back to what I learned in medical school--making diagnoses based on chest x-rays and physical exam findings.  No $1000 scans or blood markers.  Chest x-ray, ultrasound probe and a stethoscope--it might not be the most sensitive practice in the emergency room but it does make you think, rather than rely on technology.  One of the pediatric anesthesiologists at UNC loves to say, "There are three possible diagnoses for every patient: the one that ties all of the symptoms together, the one that you (or the patient) can't afford to miss, and the one that it actually is."  So true.  When patients here are paying for their own medical care or for the care of their parents, they want to be sure that they are not going to recover spontaneously before coming to the hospital.  Now, they only pay the actual cost of their care (common to see the price tag on a minor surgery to come out to a sum of 20,000 Kenyan Shillings [~$250], whereas that same surgery might cost 10-15x that in America (at cost, not even considering institutional/regional inflation) but that's $250 dollars of a very small annual income.  So they want to be sure that the hospital is needed. 

In the emergency room there are interns and nurses and then an internal medicine physician who acts as a consultant for the adults and a pediatrician for the children.  Even though I'm in anesthesiology, they still ask us to fill this role as internal medicine consultant.  I've already alluded to the fact that seeing patients in the ER is different here because of a relatively low level of malingering (compared to the US).  It is also different because the pathology and presentation is a lot different than what I was used to as a medical student.  I just admitted a young woman last night with a hemoglobin of 3, low platelets and white count--probably a myeloproliferative disorder but I'll leave that for the hematologists.  She had just been 'dealing with it' for a few months.  Her aunt finally brought her in when she could no longer stand because of the anemia.

I was seeing so much great pathology that I started taking pictures on my last night of call:

Erythema Multiforme - when the intern called me on this one he described angioedema and sores in the mouth and I thought for sure it was going to be Stevens Johnson Syndrome/TENS but ended up just having target lesions and a history of recent, new antibioitic use.

Cardiac tamponade physiology - I didn't know what was causing it.  

Enlarged mediastinum with mass effect on trachea to right.  Diastolic murmur evident.  Chest x-ray from outside hospital 5 days prior showing no mass effect.  Altered mental status and incontinence.  Couldn't rule out granuloma but looked like an evolving aortic arch aneurysm.

Jambo!

You would not believe where I have just been and what I have seen!  Kenya has about 42 tribes--the Kikuyus predominate in Kijabe and Nairobi but in the Rift Valley here, the Maasai tribe predominates and has ownership of a 700 square mile plot of land called the Mara (literally means "spotted"  and comes from the plains being spotted with only occasional acacia trees).   You might have some idea of what they mean when you see the plains from the mountain:

We stopped by a Masaai village during one of our game drives.  I was told that you don't mess with these dudes--they'll go after lions that mess with their cattle and are circumcised without flinching at the age of 16 (if they show emotion, they're considered weak and become outcasts, unfit for marriage).  Thankfully they like technology and seeing themselves in pictures:


 I drove to the Mara on Friday (miraculously made it--the roads to get there are amazingly bad.  At more than one point the hood of the little Toyota that my driver was using was submerged in water.  How it made it, I have no idea--he assured me that "I do this all the time").  When I finally made it to the safari camp (Fairmont), I was surprised by the luxury of it.  You're greeted with a warm face towel and some tasty mango juice and the staff...good grief, the staff were amazingly good at anticipating your wishes.  It really felt strange after spending 4 hours on cratered roads to get to the remote location.  After all of the recommendations to go to this safari camp, I arranged to go to Fairmont through a coordinator at Tenwek mission hospital.  It turns out that that was a very good thing because I received the "Tenwek" price which they give to medical missionaries...$150/night.  That includes 3 meals and two game drives each day.  Amazing!  Normally it's $500/night.  The other benefit of going through the Tenwek coordinator was that she inadvertently introduced me to an anesthesiologist and his son from Indiana (Magdy and Mina--Egyptian names) and a gastroenterologist and his wife from Alabama (Chris and Lois).  Being so like-minded in medicine and faith made it a lot of fun and an even more enjoyable experience--a lot of great stories going around.  Magdy and I read Scriptures in the early morning before our game drives.  It was a fantastic Easter.

White rhinos are apparently pretty docile and this one was kind enough to let me take his picture.  Shortly thereafter the little guy made after me thanks to the cackle of one of the girls in our Land Rover. 

Tomorrow morning I am lecturing before chapel to the nurse anesthetists on perioperative thermoregulation and shivering.  One of the head anesthetists asked me to lecture on something tomorrow morning (at the end of the day today), so they're not getting anything new from me!  I presented this material in Puerto Rico a few years ago and dug up a powerpoint from the e-mail archives.  This last week I am walking around the operating theater with a camera slung about my neck taking pictures at whim of people, patients and equipment.  I don't want to leave without a ton of pictures to journal my experiences here.  Speaking of pictures, I have taken over a thousand and will probably take a thousand more before I am home.  I will likely post a link to a Picasa website with my uploaded pictures, once I am in a country with more robust internet activity.  For now, these will have to do. 

The Weekend

Apparently time flies in Kijabe, Kenya--it hardly seems possible that 2 weeks ago I was packing it up in Chapel Hill for the trip here.  In medical school I took a medical missions trip to Nicaragua with good friends Chris and Elizabeth.  It was good introduction to Latin American culture but our efforts to be medically helpful were largely thwarted, it seemed, by our lacking specific skill sets at that point in our training.  We could rub delousing serum into school kids' hair and hand out albendazole but that was about it. This trip has thankfully been drastically different on that front and I think is the big reason that I am enjoying it so much.  I was talking with one of the Vanderbilt surgery residents the other night about this and she resonated very similar sentiments and has been here in Kijabe since September!

So this week I have typically been supervising a Kenyan anesthetist student in one operating room and then performing peripheral nerve blocks or helping the regular nurse anesthetists in other rooms.  The sum of it = very busy days.  Working with the students can be harrowing.  Shoot, working with the senior anesthetists can be harrowing.  I had one ask me if she could mix her Ketamine and Propofol into the maintenance IV fluids for the case for which she was giving sedation.  She was dead serious.  After I suggested why that might be a bad idea, it was as though it had never occurred to her why that might be a bad idea!  She and several at her level give anesthetics every day without any sort of oversight.  We're friends and have good laughs but yikes!  I do not say that out of condescension--in reality the quality and safety of anesthetics delivered at Kijabe is probably some of the highest in the country, and I think that the nurses do receive good training here.  This trip has been eye-opening with regard to the quality of the medical care that we have in the U.S.  Today we did a rigid laryngoscopy on an infant that I have been caring for in the ICU for the past 10 days--she has recovered from pneumonia and had recurrence.  The reason?  Aspiration of nasogastric tube fed breast milk.  The solution?  Surgery?  Nope.  Palliation.  Yup!  Really?  In the States that child gets a gastric fundoplication, a G-tube, some Ranitidine and 73 more years of life.  Earlier this week I was told that a newborn with tracheoesophageal fistula was coming to my room for thoracotomy and closure.  It was the end of the day already, so the powers that be decided to move it to the morning.  The baby died that night...never made it to surgery.  Again, in the States that child would have gotten her surgery and probably many more years of life.  It is sobering.

Well, tomorrow I head out early in the morning to hike Mount Longonot with some friends from internal medicine and then on Saturday I leave very early for a safari in the Masai Mara.  Apparently there is no better safari experience in all of Africa, so I am stoked!

Placing a caudal block in a hypospadias kiddo--working with student anesthetist.

Teaching femoral nerve block to one of the nurse anesthetist and a student.

I was late for lunch--no rice but more veggies!

Dessert Night

Tonight I went to Mark and Sue Newton's house for 'dessert night'--Mark is the anesthesiologist from Vanderbilt who spends all but 10 weeks of his year in Kijabe directing the anesthesia services and training Kenyan nurse anesthesia providers.  Monday nights give a chance for the short term physicians to meet up with those who are here on a more long term basis.  It was fantastic talking to Mark because he took a very similar path to the one that I am heading down--he did a pediatric fellowship at Denver Children's and did a pediatric cardiac anesthesiology fellowship before starting into practice.  He had some good insights into missions and training--I appreciated hearing them.

This past weekend I was on ICU call from late Saturday morning until signing out to my new friend, Hans Yehnert, with internal medicine on Monday morning.  It was a looong weekend.  Saturday night one of the general surgeons called me at home and asked me to come in and help him with a trauma case--a 32 year old girl who was hemorrhaging into her abdomen following a cab accident.  I came in and gave the anesthetic and then, since I was covering the ICU admitted her to the unit postoperatively.  While I was in the OR (or 'theater' as they call call it here), I was called emergently to the ER for a patient who was stroking and needed evaluation.  I would never leave a patient in the OR in the States in these circumstances but the trauma patient had responded well to resuscitation and had a conscientious surgeon and circulating nurse.  In the ER I find the poor fellow who is stroking--blown left pupil, agonal breathing...the whole bit.  We don't have a CT scanner, so the neurosurgeon's decision tree is based purely on physical exam findings in the acute phase.  It looked like a pontine hemorrhage and a big one--I agree to admit him to the unit for observation 'just in case' we're wrong, intubate him and head back to the OR.  As I'm trying to leave the ER, the clinical officer asked me to review some simple x-rays she'd ordered to see if I agreed.  Some skull films and a chest x-ray.  I told them, "you do realize that I am in ANESTHESiology and not RADiology, right?"  They didn't seem to care...ha!  So I gave my guarded opinion on them and it was back to the OR where Peter Bird, the australian generalist was finishing up with our trauma patient.  In spite of 5 units of whole blood (~2.5L of volume), she was still hypotensive on return to the ICU--I guess the disrupted bowel probably caused measure of bacteremia/septic response because she needed dopamine for the rest of the night.

Kenyan Registered Nurse Anesthetist students--lecture day: I asked them to let me pose, so I'd have proof that I did some teaching in Kenya.  They thought it was pretty funny.

Here I am with Steve and Joseph in the ICU over the weekend.  I thought they were interns because of their lab coats but no, definitely not (unfortunately, it would have been nice to have interns filtering the ICU calls!) 

Myelomeningocele child--you can probably see the spinal cord defect being scrubbed.   For perspective on the child's head (severe hydrocephalus), see the adult's hand to the right.  I think this kiddo was 2 months  old. 

Pediatric ventilator--old school but not actually a bad little ventilator.  Rate is set by adjusting the I:E times--kind of cool for nerdy anesthesia types, I guess.

A sweet cook named Hellen makes my dinners and leaves them in the refrigerator every M-F.  Tonight I found this specimen container labeled "path" which I'm afraid was a specimen container for surgical pathology at one point.  Tonight it contained delicious chili and thankfully, it did not smell like formaldehyde!  I was too hungry to worry about it for long.

Week 1

It's Friday night here and I am exhausted!  It makes me chuckle how insane the days are--I mean, the things that are done to 'get by' just never cease to amaze.  I don't know where to start in expressing my thoughts--there is so much to take in with just being in Africa, let alone experiencing the clinical medicine side of Kijabe.  I am on call all weekend for the ICU but have lectures to prepare for the nurse anesthesia students for Monday morning--so it'll just be a work weekend.  That's ok, next weekend I'm going to hike Mount Longonot and see Lake Nakuru (flamingos!)...

Big, juicy living room

Kijabe Hospital is a Christian mission hospital that was founded in 1915 and serves as a referral center for the whole country, really.  With that wide referral base, they see a lot of very specific diseases...for example, and as I mentioned previously, neural tube defects are repaired daily here (and many kinds in a day, at that).   As you can imagine, a 300 bed hospital (with outpatient clinics) requires a lot of support staff and so there is a community around the hospital with schools and rickety shops and the like.  In the evenings after I am out of the hospital, I have been exploring the area on runs down the mountain and through the brush.  Let me tell you, running at 8,000 feet is no joke--I've got more than a few hills that I'd like to conquer in the next two weeks.  Wildlife is everywhere on these runs and I'm not going to lie, it's a mix of wonder and fear--so many unfamiliar animals flying/running out as I go.  It's ok, no mambas or rabid baboons yet!

Trail to my place--it isn't much to look at but check the view...

My favorite part of this trip so far is to see the enmeshment of the spiritual in the medical care of these patients.  Part of our 'OR timeout' before incision is made is to pray over the patient, and I gladly do (don't worry, I open my eyes for the long-winded ones).  It is as though things are as they should be (and will be) when Jesus is praised openly for recoveries and equally trusted openly when things don't look good.  It is liberating in both circumstances: liberating from pride in the successes and liberating from depression/frustration in the failures.  My tendency is toward seeing myself at the center of success or failure, underscoring the importance of praise/genuine thankfulness to me.

Rift Valley, aka Valley of Megiddo "Armageddon," extends from Africa to Jerusalem and is right out my back door!

TIA - This is Africa

It's hard to believe I'm only 3 days into my clinical duties here at Kijabe Hospital--it's been such a surreal, action-packed experience.  Wireless is at best sketchy here--so I will summarize my week to this point, in anticipation of blogging more if/when the satellite receiver is up and running.

We flew into Nairobi Saturday night, after an uneventful trip through Amsterdam.  Though the two eight hour legs didn't feel terrible, I was jet lagged for my first 48hrs here.  There is only so much that Ambien can do when you're getting asked to stand up every hour for the window-loving 5 year old two seats over.  I guess I can't complain--being able to travel from NC to Kenya in less than 24hrs is pretty amazing.  So it was on to Kijabe on Sunday after a night in Nairobi.  We had a quick walk-through/orientation to the village on Sunday and after getting my ICU call pager and locker etc. on Monday morning, it was off to the OR. 

Now, starting in the OR here has been...ummm...interesting.  Very little is prepared for--preoperative evaluation?  Ha!  I'll give you an example.  Yesterday I finish case number 3 for the day, which was a myelomeningocele repair in a severely dysmorphic 3 month old.  I extubate this child in the OR--against my learned instincts--there are no more pediatric ventilators in the hospital (the two that are, are being used).  It's a little dicey but the little dude does alright.  I drop him off in recovery and return to the operating room where my next patient (had a tethered cord for release) awaits on an operating table that has not yet dried from the cleaning wipe down.  I know nothing of the patient--he is an infant and has Somalian parents.  We're proceeding.  The tech. fetches me an appropriately sized, washed breathing circuit...I scramble to find appropriate drugs and we proceed.  7 cases in the OR that day--6 major cord defects and a shunt.  Sweet sassy.

Go to medications for cases include: pancuronium, atropine (no glyco.), morphine/meperidine, thiopental and halothane (for mask inductions).  Thankfully there is isoflurane for maintenance now!  Basically, if it's cheap and nobody else wants to use it...those are the supplies that accumulate here.  Quincke (cutting) spinal needles--yes please!  Disposable pulse oximeters are used until they literally fall apart.

Other cases that I've been involved with this week already include:
- Continuous spinal for hemiarthroplasty in a 90 year old Somalian woman
- PEA arrest in a 2 year old for posterior fossa craniotomy for tumor excision (arrested while prone--revived after 5 minutes of PALS)
- Surfactant administration to a 35wk infant while on ICU call (I'm the attending and by far the most experienced--yikes!)
- Intubation and subsequent extubation of a 29 year old with massive retropharyngeal abscess after mandibular fracture--suctioned .5L of puss from the back of his throat before extubating him in the ICU last night because I needed his ventilator for another crumping patient
- Inverse ratio ventilating a 2 kg infant with sepsis from pneumonia

There's so much more that I could write but dinner awaits and so does shower and bed!  I will try to write more frequently and with pictures once I have an internet connection.  I have a bit of humor to share re: Dr. Anderson but that will have to wait until the next time I write.  Let's just say--I think he might be looking forward to teaching seminary up at Kitale after this week! 

After years of thought and several months of preparation, I am finally ready for a month at Kijabe Hospital in Kijabe, Kenya.  Dr. Jay Anderson and his wife Holly will join me for the 24hr journey to Nairobi on March 23rd and I will work at the hospital until April 15th.  These are exciting times for me and I plan to write about a lot of my experiences and related musings here.  With the help of UNC's department of anesthesiology (anesthesia technicians, attending anesthesiologists, medical suppliers, chairman/program director), I am amply supplied for this trip--so much so that I feel humbled and immensely blessed to be able to work for such an amazing department.  Here's what I'm taking:

Stay tuned.  More updates to come!