warren here...

At the end of one week of African medicine it has already been an experience. Figuring out how I fit in continues to occupy a significant part of my day. I am happy to be interacting with many African MD’s, nurses and CO’s(physician asst’s). Kijabe Hospital is a training center for nurses, medical interns, family practice residents, CO’s…and also has MO’s(medical officers) who continue to work after their internship year as they pursue coveted spots in Kenyan residency programs, which they will have to pay for, rather than get paid like we do in the US. Patients arrive in cars, buses, taxis, carried by family…There aren’t any ambulances to bring people. They arrive in every level of acuity and sickness. In the last few days I have treated infected open fractures, heart failure leading to cardiac arrest and death, a young man with recent pneumonia who shows up with an empyema that we could drain with a chest tube, a young woman treated for malaria with abdominal pain who actually has appendicitis…The Western doctors in the hospital come and go regularly and it is never certain what kind of physicians you will actually have available. Normally there is no radiologist, however, for the next year we will have a great doctor from Toronto who can even do some invasive radiology. For the next 2 months we have an experienced Australian surgeon who can make use of the laporoscope equipment that the hospital already has but can rarely make use of.
For my medical friends, here is a little vignette: 49 year old complains of shortness of breath, weakness and high heart rate for one month. Vital signs: HR 160, O2 sats 80’s and low blood pressure. I asked him, thinking that he couldn’t live like this for more than one day, how long he has actually felt this bad. And he says, “One month”. I don’t believe him. However, he comes with an EKG and a CXR from 3 weeks ago, done at a clinic in Nairobi by a doctor who looks like he is a Hem/Onc specialist. The CXR shows significant CHF and a very large heart. The EKG shows HR 120 and not in sinus rhythm. So what do they do for him? I am not sure, but he also comes with a detailed report from 5 days later of an upper endoscopy. His stomach looked fine. You wouldn’t want to start any cardiac meds of course. So after that I actually believed that he was feeling like this for the past month. He started to decompensate. And, as a good ER doctor, I thought…let’s treat him. Nitroglycerine seems like a good idea, but we don’t have any. I would like IV morphine but, after a call to pharmacy, they are out of that drug. How about an IV beta blocker? We don’t have IV beta blockers, but we have Propranolol PO, so why not? We did have Lasix, and oxygen is a drug. However, in the end, a month of untreated heart failure was too much for him. This is an example of inadequate medication and support and also a lack of appropriate decision making. In contrast, I am working with a 3rd year resident level Kenyan doctor who has a fund of knowledge and ability to come up with complex differential diagnoses that is much more than my ability. It can be astounding to see Kenyan trained physicians who have the ability to function at a high level in a Western hospital but are left working with so few resources and little opportunity. Not to paint Kijabe Hospital as a backword undeveloped facility because in fact it is a true light throughout Eastern Africa; I have treated patients who have traveled from as far as Somalia, Sudan and the far edges of Kenya. Injured people on the streets of Mogadishu know to come to Kijabe.