Perspective

Today I completed one of my goals while in Kenya: I ran with a Kenyan! Actually, I ran with about 30. I got out of clinic a bit early today, and needed to go for a run. So, naturally, I ran to the highest point around. It was beautiful. After taking in the scenery, I started to run down. However, the path went by a primary school. Not being used to seeing a mzungu in shorts running by, they started shouting with excitement. The next thing I knew, I was running with 30 barefoot Kenyans running behind me. Despite not being able to speak the same language other than greetings, I started to yell with excitement. They would repeat me. Then I stuck out my arms, acted like an airplane. They repeated. We carried on like that for 3 miles. I'm sure they will be talking about the crazy mzungu for days.




Clinic, like always, was crazy today. You never know what is going to walk in. My first patient had a mandibular mass half the size of her head. (Never mind the skeleton in the background, I was examining this patient in a storage closet)






Next I saw a patient with elephantiasis. It was classic. She was a Massai woman, decked out in her classic African wardrobe. This is an infectious disease, where microscopic worms named, wuchereria bancrofti, (awesome name, right?) live in the lymphatic system. They are spread by mosquitos, which I recently learned are the most deadly animals in the world. Many diseases are spread by them.



Working in a foreign country can be frustrating for many reasons. The cultural differences in concepts of time, appropriate clothing, and food are a few. Usually I feel pretty comfortable traveling, and don't have any issues adapting. The issues above haven't been an issue. However, the language barrier is starting to get to me. After the time-consuming process of bugging a nurse to interpret for nearly every patient, and all the cultural misunderstandings of translated words, I was getting a little unnerved by the end of the day. So naturally, when a 23 y "confused" male walked in, I wasn't happy. He was talking nonsense, even before his words were translated. At first I thought it was a psych patient and my frustration with the situation increased. Then I looked at the vitals (yep, having to rely on them a lot when you can't communicate) and noticed his pulse rate was 40. (Cushing's reflex- a response to increased intracranial pressure) I started to take him more serious. It turns out, he had a history of head trauma three days ago, had projectile vomiting, but no focal neurological deficits. Of course in the US, you would get a head CT immediately and consult neurosurgery. Here you rely on the physical exam skills. Being unable to assess for papilledema, (I would have killed for a PanOptic) I had to assume there was increased intracranial pressure. I ordered a head xray. He had a compound depressed skull fracture. Whelp... teachable moment. Thanks God.


Perspective:

The past year or two, I have been almost bitter at times towards medicine. Why do physicians work so hard? Why am I expected to work 6 days a week, round on patients 7 days a week, have my call shifts be LIMITED to 30 hours in the hospital and an 80 hour work week is normal? It's especially hard when most of my college friends are working a 9-5, making money, and moving on with their lives. One of my med school friends surveyed our class with the following question, "Would you do medical school again?" The overwhelming majority said no. Not exactly the best attitude to have as residency draws ever nearer.

I feel the need to tell you about one of my surgery chief residents, Dr. A. While serving here, I have had the opportunity to work with incredible physicians and residents. They work as hard, or harder (no 80 hour limit here) than in the US. My senior resident Dr. A is from Ethiopia, and a PAACS (Pan-African Academy of Christian Surgeons) resident. He went to medical school and completed his internship in Ethiopia before the hospital was closed. He then spent two years in Cambodia training until that program ceased to exist. His last year was spent here, and with one year to go, he's looking forward to returning to Ethiopia. His future? To take over for the only surgeon at the hospital serving a catchment of 800,000 people. The current surgeon is leaving the day Dr. A gets there. He will be on call 24/7. No weekends, no vacations.

Speaking of vacations, I live for them. That's what allows me to work hard; knowing that I have something awesome to look forward to. Last year, this Dr. A got one month vacation from residency. He went home to Ethiopia to see his parents. Before he even arrived home, the only surgeon at the hospital near his parents house heard he was coming, left for the month. My resident spent 27 straight days and nights operating, rounding, and staffing the hospital by himself, until he had to return to Kenya. For him, residency is a vacation. Next year, he will be it. No backup. When he decides to sleep, or rather, nature forces him to sleep, people will die. The weight of responsibility that awaits him is unfathomable to me.

So, a little reality check, with my residency match rank list due in a month. Sure, I'm going to work hard. But suddenly, and perhaps just when I need it, God provides a bit of perspective.

Daktari?

In Kenya, I'm daktari. What have I done to deserve this title? Well, not much. I could be a white guy with a high school education, and when I walk through the halls of a hospital here, I would be referred to as daktari. I would feel a bit guilty about this, if I hadn't trained for the past 3 1/2 years. And the fact that anyone here who works in a hospital, whether Kenyan or western, is called daktari. Still, it doesn't feel quite right. Sort of like trying on a new shoe that's a little too big. I guess I better get used to it soon...

As this is my first post in over two years, let me make a disclaimer. You will find a stream of reflections on my experiences at a mission hospital in Kenya. I don't claim that my thoughts will make sense, or that I will even agree with them a day after posting it. Just a stream of jargon, with a story or two for entertainment.

I have now been here a week. I'm rotating on the surgery service; days
are usually from 5:30am until 6:30pm. I feel like I'm actually really
contributing to the care of the patients here. As opposed to the US where
medical students are pretty limited by what they can do, and the fact that there are a number of
residents and other students all fighting for the same procedures.
Here it is often just me caring for the patients. I have seen amazing
surgeries that I would have never got a chance to see in the US. And, I am
usually the First Assist on every surgery I scrub into, or they will
actually let me do the surgery and they will be my assistant, directing my
actions.

I'm not sure exactly how this happened, but I have taken over the
female surgical ward, which I round in every morning and evening. I'm
taking care of about 20 women with complicated wounds, pancreatic cancer,
bowel obstructions, trauma injuries from drunk husbands, etc. Most of them
are HIV positive, a real problem here. (And a little scary for me after I
splashed blood in my eye while suturing a massive head laceration of a
motorcycle accident victim) However, since former president Bush's PEPFAF
initiative, HIV has changed from a death sentence to a chronic illness that
people can live with for years. Before this program, no one here even
wanted to be tested because they didn't want to know they were going to
die. Now, people want to know their status and their first question is,
"Can I get the medicines?" Obviously, this has huge implications in
terms of public education and in spreading the disease. There is still a
large social stigma associated with the disease however.

One of the comforting things in the US is that now mater how sick a patient
is, I know that I'll always have back up. I can call my intern, resident,
senior or attending if I had to. Here, there is no back-up. I've had a few
experienced now where I was called into the "Casualty" (the equivalent of an
Emergency Department in the US) to encounter a patient who was comatose.
The casualty here is staffed by a nurse, who determines whether the patient
is sick or not. If not, they will be sent home. If they are sick, they
determine if it is a medical or surgical problem. Then the intern will be
paged.

Now, no mater what reputation interns have in the US, we have pretty
good training. Two years of clinical medicine may not be much before
becoming an MD, but it is far more experience than what a Kenyan intern
gets. With only one month of required clinical rotation left before I graduate
medical school, I have quite a bit more experience than the interns here. And, I'm gaining more experience all the time.

Last night I staffed casualty for several hours without much support. I had 4 trauma patients come at nearly the same time. They were bleeding profusely. One had been beaten with a metal pipe by her son. One man was in a land dispute with a Maasai warrior, narrowly dodged the arrows shot at him, only to have his ear and half of his face sliced off by a "panga" or machete. Another man was bitten and beaten by his neighbors who heard him drunk and hitting his wife. Good thing I have completed a few months of Emergency Medicine this year. The unfortunate part is, when I wanted to start the two large bore IV's and run fluids wide open, I had to start them myself. Then, when I ran out of fluids later that night, I realized I need to be a bit more judicious in medical resources. I also ran out of sutures, lidocaine, gauze, gloves...

Another story. I was called into casualty while on call. I encountered a 80
year old patient, unresponsive, laying in bed. One leg had been amputated, the
other clearly had necrotizing fasciitis (a very serious infection that
requires surgical cleaning). I had seen several septic patients in the past
few months while in the ICU. In my head I began to recall my training,
"Airway, Breathing, Circulation, IV, O2, Monitor..." The only problem was,
in the casualty area, there are no blood pressure cuffs, no monitors, etc.
Vitals are NOT nicely displayed and recorded every few minutes on an electronic medical record that can be dropped into your pre-formed templated note. I had to
run to the ICU to find a Oxygen saturation monitor. Turns out it was 65%.
Not really compatible with life for very long... Anyway, the guy needed
immediate surgical intervention after being stabilized. He was sent home to
die, being unlikely to survive even the anesthesia required for the
surgery. People here don't come to the hospital until they are on deaths
doorstep. Whether it is because they are stoic and the people in general
don't show much pain, or they don't want to have to pay for the care, they
often present in very late stages of their disease.

No matter what you think about health care in the US, I'm coming to
realize it is very good. You can argue whether health care in the US
is a privilege or a right. In Kenya, it is defiantly a privilege. I
saw a 3 month old in clinic this week with a meningocele
(a protrusion of part of the spinal cord through the spine). Essentially,
this baby had a 30 cm mass protruding from her lumbar spine. This was the
first time she had seen a doctor, as the mother had given birth at
home, and much to her surprise, the mass did not go away. Unfortunately, she did not
have the money to pay for the surgery.

Despite working at a missionary hospital, the patients still have to pay. What they pay
covers only their operating cost. The missionaries salaries,
all building projects, and many of the medicines are provided by
outside resources. However, by making the patients pay, even just to
cover costs, the hospital can keep running, and the Kenyans aren't
becoming dependent on handouts. Instead, they are owning their health
care and perhaps are more appreciative. The hospital is actually
staffed almost entirely by Kenyans. The majority of the economy in
the surrounding area is fueled by the hospital.

The drawback? People like this 3 month old girl bear the burden. I'm
not sure how much longer she will survive without the surgery. The
skin separating her spinal cord from the bacteria that could end her
life is paper thin. So, we sent her away to find the money. Many
times the village will try to pool their money, sell a cow
(literally), and take care of their own. I scheduled her to return to
clinic on Tuesday. Hopefully she will come.

I don't know if there is a "best" way to do health care, but what we
have in the US is pretty good. One of the nice things about going
into Emergency Medicine is EMTALA. While working in the US, I will
never have to worry about a patient being able to afford treatment.
If they step into the ED, I'll treat them. Wealthy CEO, illegal immigrant, drunk homeless person, it doesn't matter. Figure out payment later. You could argue that this might bankrupt US health care, but selfishly, it's nice to not have to worry about that.

The mission hospital's policy is that you don't leave the hospital
until the bill is paid. They have gates around the hospital, less for
our protection, but more to keep the patients in until they pay. I'm
not sure how well this would go over at home. Incarcerating patients
who can't pay hospital bills might go straight to the Supreme Court.
I had one of my female burn patients ask me to take her off the high
protein diet (of 1 egg with every meal) because she was afraid she
couldn't afford the bill. I guess she doesn't want to be locked in.

I have a million more stories and thoughts, but this is enough for now. Tomorrow begins another week. "Daktari" is expected to round early.