A part of that...

In the hopes that someone is still reading this and enjoying it, I shall continue to spend my evenings writing about my African adventure. Though, I must admit today’s entry is less exciting and more disconcerting.

This is the hospital compound. Outpatient to the right, main building to the left. Painted pink, some say because the Administrator is a woman, the much respected Dr. Juliana
(Can you tell I've been playing with the panorama features of my camera?)

The day started as most are beginning to start, that is to say, on Kenyan time. The “Major Ward Rounds” that were scheduled for 8:30 actually started at 10. Not that I was counting the minutes or anything… Besides, I had to actually dress in a white coat today. And I discovered that you don’t want to be the Mzungu doctor in the coat hanging out in the hallway waiting. You get asked to look at all kinds of things.

Major Ward Rounds are the equivalent of attending teaching rounds in the US, with the exception that they also constitute work rounds. To explain for those of you that don’t have to spend your life rounding, and pre-rounding, and work rounding, and table rounding, etc… Work rounds are a functional assessment of the patients on the ward. Each patient is seen, it is presumed that the team is aware of the underlying problem and recent care, relevant new issues are discussed, and treatment plans are made for the day.

On attending teaching rounds… Wait, I should probably define “attending”, no? An attending physician is a staff surgeon, completely done with training, and if not already board-certified (some 1st year attendings), then absolutely board-eligible, meaning that they have completed an accredited surgical training program. So, attending teaching rounds in a place like St. Vincent’s (may it rest in peace) or Columbia would have a member of the team present a snapshot of the patient’s presenting problem and subsequent care. Ordinarily, the attending would then take the opportunity to teach/question the residents about the disease process, the surgical procedure, or any complication that might be present. Unless the issues discovered on work rounds are significant or perplexing, the minute details of the patient’s care are not discussed. These are not generally daily events, but rather done on a weekly basis.

By combining the two, as is done here at Nyanza PGH, you get prolonged rounds of increasing confusion. We only finished Ward 1 by 12:30, when the attendings had to go to a meeting. At which point, I was expected to round with the house officer on Ward 2, which I did until 2:30, until we hit the orthopaedics rooms, where I had little to no knowledge to offer.

Lots of people, little rooms, mass confusion

What I enjoyed, and had to prevent myself from giggling about, was that the “feel” of these rounds was absolutely the same as in the US. The interns were terrified and usually weren’t as familiar with the patients as the staff surgeons wanted them to be. This then led to some gentle and not-so-gentle ribbing. Some of my favorites? “You’ve been on this ward six weeks, this patient has been here for 2-1/2. How have you been taking care of her when you don’t know anything about her?”, “Look at her wounds, you’re looking ar her wounds? Are those the wounds of a skin graft? Think before you talk to me”, “Just because you start a patient on feeds doesn’t mean to start planning their discharge and forget about them. You have to look at them, what if they get distended? What if they vomit? Look at his belly, he’s not going home today!”

Ahhh, not to be the low man on the totem pole any more… ;) The blank stares some of the interns had on their faces were worrisome, and some are clearly stronger and more prepared than others. Perhaps it’s just because I have so little responsibility other than the operating theatre, but when, at the conclusion of rounds, I said to the house officer, “Okay, so we need to book the two exploratory laparotomies, the fasciotomy and the radial reduction”, he looked at me with absolutely no glimmer of recognition that those plans had been laid out. He refused, only booking the radial reduction, because that was all he remembered. Woe was him at the end of the day when the staff surgeon was roaring that the ex-laps had not been booked. (Have I mentioned that particular surgeon is the tallest and broadest Kenyan I have seen here?) No harm, no foul. We did the fasciotomy, he and I will do the ex-laps first thing tomorrow, and the radial reduction needed another Xray before going to the OR.

This is the "Pre-Op" area. The metal stretcher fits perfectly into the niche in the wall. Ward 1 is just through the locked doors in the background. The patients are wheeled in on the black gurney, transferred over the wall to the white. That's it. The pediatric patients are generally just carried everywhere.

The more disturbing part of my day was down in Ward 1, which is an amalgamation of pediatrics and women. (Ward 2 being the male surgical ward). I’m not even sure I can write coherently about what I saw, because my heart is still aching. Suffice it to say that a lot of food preparation in Kenya is done in large pots of boiling water, and those prove to be a hazard to babies and toddlers. All in one room, 11 young children with horrifying burns, being tended to by their mothers. If they survive this ordeal, I wonder what their lives will be like as children and adults. Honestly, the images will haunt me for a lifetime.

Oh, the Kenyan training system! Straight from secondary school, young men and women enter medical school, a five-year curriculum. At the end of that time, they apply to do internships at the medical facility of their choosing. Places like Nyanza PGH are somewhat competitive and require formal application and selection, but students can choose to be trained at smaller district or local hospitals. Upon successful completion of that year, they are then prepared (hopefully) to be general practicioners in the community or to serve as house officers at institutions. If the young man or woman is from a wealthy family, they can choose to go immediately into Masters training for a specialty. Most, however, work as house officers for a time to raise the funds for specialty training, i.e. Surgery. There is no formal training to become a particular type of surgeon. The staff surgeons I’m working with have tailored their practices and/or sought training outside of Kenya for sub-specialties, such as ortho and pediatric surgery.

All in all, after three days at the hospital, I can genuinely say that I’m glad I came, and I look forward to the surgical adventures I have remaining.

Not really relevant to today's blog, but this is the hospital laundry "facility" and I liked the picture ;-)

Oh, and I discovered a soda drink called Stoney Tangawiza that is amazing!

Goodbye until tomorrow...