Hi! Ho!

Unclear how to proceed with the narrative of this blog. To keep my captivated audience of a dozen interested…

I started work today, which means that this blog could turn into a boring recitation of operations done. But, I feel like I pack too much in on the weekends to talk about all at once, so…

My strategy, henceforth, will be this: If the day is a momentous one, then I will describe it and stick solely to events of the day, otherwise I will fill in with tidbits about my weekend activities. That being said… A preview of coming attractions, if you will…

Today, my first day at the hospital
Tomorrow, my gloriously relaxing Sunday at the beach
Wednesday, my first hospital rounds
Thursday, my wildlife tour of Lake Victoria
Friday, my attempt at being one of my favorite female characters, Claire Fraser
Saturday/Sunday, who knows what the weekend will bring ;)

Still combating jet lag, I managed to do the equivalent of “snooze” by resetting my Safaricom phone alarm to give me 15 more minutes. Which turned into 20, which turned into 30, which turned into my tuktuk driver calling to tell me he was downstairs while I still had a mouth full of toothpaste. Glorious start to the morning. Luckily, I had all my surgical stuff in one place and was able to throw myself together pretty quickly.

And thank goodness I rushed to be at the hospital at the appointed time. Surely, the matron would be waiting for me on the dot of 8 o’clock, to look at me over her steel-rimmed frames if I were even a moment late. Kenyan time being what Kenyan time is… ::huff:: I sat outside the matron’s office until 9:15, at which time I was dispatched to Dr. Juliana’s office. She continued signing and stamping papers as she welcomed me and told me to wait outside, as an intern was coming to get me and take me to the ward. She, like everyone else I encountered, thinks that my stay here is too short. To be sure, it’s a six week elective, the last week of which is my vacation. It takes three days of travel each way, add in weekends and flight schedules and it gets whittled down pretty quickly. It’s the sly Kenya smile that eats at you, you’re not sure if they’re just commenting or judging. I suppose if I think about it, it’s not limited to Kenyans…

Karroki (pronounced like the entertainment every Japanese businessman loves) was the intern assigned to take me up to the ward. The trainees here are not so coddled well-protected as their counterparts in America. There are no work hour restrictions, and he apologized that he was fatigued but that he had not slept in 48 hours. Strong work, Karroki, strong work.

Typical Ward charges (divide by 80 for dollars) There is a similar list outside the OR. Major procedure? 5000 KSh

We got to the ward, and though I could see hope shining in the faces of the house officer and the day nurse, I was not there to bathe patients and check wounds. Their ward is overfull, and they consequently are overworked. Though I have no qualms about helping to take care of the patients on whom I operate, my primary role here is to be in the OR, ahem, to be in theatre. (It’s a British thing, but, hey, I can be a theater geek in more ways than one!) Maybe that’s a horrible position to hold on to (go ahead with your sly smile and judge me, I don’t care…), and I will do as much to help as I can on Wednesdays and Thursdays, when the theatre is not scheduled (if I’m going to use theatre, you have to mentally pronounce schedule as shed-ule)

The wards are reminiscent of what you see in films of the 40s, perhaps, or the tubercular sanitariums for the poor. A long simgle hallway, one side with louvered window panes looking into the courtyard, the other with doors cut out of the concrete slab. Each opening looking into a bare, high-ceilinged room with only a single row of windows at the top of the opposite wall. Three or four plain iron-frame beds with plastic mattresses that may or may not have sheets. Small rusted, but painted metal bedside tables for a few personal possessions. Family members coming in and out, feeding their relatives, changing their bandages. Some patients didn’t have rooms and were being kept indefinitely in wheelchairs in the hallway.

The intern had started a brief rounds of sorts, when his cell phone rang calling him to theatre. But, before I follow him there, let me paint for you the picture of the two patients he was able to present to me.

The first gentleman presented with three days of not having a bowel movement. His abdomen was slightly distended, but he had not experienced any nausea or vomiting. Within the past year, he had a right inguinal hernia repaired.

In the US, that would buy you a tube to decompress your stomach, a CT scan, a catheter in your bladder and IV fluid. Here, he got an X-ray and an enema. He is now having diarrhea and his abdomen is not distended. In short, he ended up likely okay, but without an expensive work-up. Score 1 for Kenya.

The gentleman in the next bed, who was completely unresponsive to verbal stimulus, presented with wet gangrene of his right foot. A known diabetic, the decision was made to proceed to above-knee amputation to prevent spread of infection. In the US, there probably would have been an initial debridement to stop the infection, concurrent use of antibiotics, evaluation of his arterial vasculature to determine the extent of his peripheral vascular disease, perhaps some attempts at improving vascularization with various balloons and stents, ultimately resulting in an amputation of some sort, likely more than one in an attempt to preserve function. End result would likely have been the same. Score another for Kenya. Or so I thought, until I heard the next statement.

“But now he’s in a coma because we can’t really get his sugars under control”

That is something, with our point-of-care testing, insulin drips and skilled nurses, we have learned to control, if not easily, at least better than having a ward patient in a diabetic coma. Score 1 for US.

At that point, it was down to theatre.

The six ORs run down the right wall

First point: they are serious about not wearing street shoes into the main theatre and adjacent areas. There are mid-thigh high walls between “outside” and “inside”. These ain’t walls with gates. These ain’t a painted red line. This is hard-core, take off your shoes and climb over the wall. And the shoes that await you on the other side? Not the clogs I love so much (you know it, you want some, the Dansko clog is the sexiest thing you’ve ever seen, no?). White rain boots. I had to borrow a pair today, though I went and bought my own after work.

Next point: The caps and masks that we put on, take off and discard numerous times a day? Nowhere to be seen. Everyone has ONE of EACH that they keep in their locker. Not even just one per day. Just one. ONE. Luckily, I brought masks with me, and am being as frugal as I can be. Caps, I forgot, and was given one to borrow for the day. Fortunately, there is a surgical supply store near my guest house and I bought a pack of 100 for 800 Ksh ($10), I will use them frugally and give the rest to the staff.

Most important point: Almost nothing is disposable. The electrocautery pencils that we blow through like water get re-sterilized here. The gowns are the fabric kind that some hospitals still have lurking around, but are used by nurses and anesthesiologists as coats for when it gets chilly in the OR. Gloves are disposable, but are so thin that it requires wearing two. (Again, I brought my own). Endotracheal tubes are re-used, same with nasogastric tubes. Sutures are only opened when asked for, there are no such things as free ties. If you want a tie, you use the back end of your suture and keep it as short as possible.

At the completion of a case. The back table doesn't get changed between cases or between days from what I can tell.

Oddly enough, even with all the differences, surgery is surgery is surgery. Tissue planes are the same in Kenya and New York, vessels bleed the same and organs are where they’re meant to be. The suture you want is never in the room, and circulating nurses still take just as long to do the six tasks the surgeon asks for at once as they always have ;-) Instruments have slightly different names. Forceps are tweezers, clamps are forceps. And forget any fancy name for a clamp, you just take what you’re given. Equipment still doesn’t work right all the time. The pediatric surgeon I was working with today was getting frustrated at the bovie and the suction not being set up and working and didn’t believe me when I told him the same thing happens in America!

Cases today:

Observed: repair of a tongue laceration in a 2y3m boy. The thing that struck me the most was even for a simple procedure such as this one, the surgeon was constantly talking to the intern, describing what he was doing, why he was doing it.

Scrubbed: nephrectomy (removal of kidney) for a 2y8m boy with a nephroblastoma (tumor). Despite having met me just minutes earlier, he let me do the whole thing. Un-freaking-believable.

Scrubbed: removal of an infected bone fragment in a 5mo boy with a fractured radius. For my own peace of mind, I’m not thinking about how a 5mo boy sustained a fractured radius.

Have I already described the training process in Kenya? Next time, perhaps ;-)