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Anesthesiology

Report from Kenya - January 2009

As I looked into the face of a mother-of-two in our “quaint” (another word for small and poorly equipped) Post Anesthesia Care Unit (PACU) while watching for the evidence of stable vital signs, I was reconfirmed in my thoughts that training African anesthesia nurses for African pathophysiology is the best calling in all of medicine.

 Just as I had arrived home after a long day in the operating room, I was called on our internal phone system (Remember “Mayberry R.F.D.” and Sheriff Taylor calling 234 for the barbershop) at 286. The caller said, “Come, Mary needs your help!”

It was 8 p.m. as I began jogging the two minutes from my home to the hospital down a rutted-out dirt road. Passing the cemetery where we recently buried a teacher from our children’s school, while quickly glancing over to check if our water tank was full, I attempted to guess the anesthesia problem awaiting me in the operating room.

When I arrived, Room Five had been redecorated with islands of blood on the green-tiled floor and a blood-soaked- trolley which had been hurriedly pushed into the corner so that the resuscitation of this mother could begin. I could hear Mary giving orders to everyone in the room. The patient had a ruptured uterus and although the patient was rushed with the help of the security guards, the midwife, the scrub tech, and two Registered Nurses to Mary who was waiting in the operating room, the patient was in hypovolaemic shock and arrested.

Mary was one of our graduates of the first Kenya Registered Nurse Anaesthesia (KRNA) Program, and she was now leading the team in these resuscitation efforts to save an African mother. I joined in the efforts, and as we placed intravenous lines, called for blood, performed chest compressions, pushed adrenaline (epinephrine for our North American readers), and prompted the two members of the surgical team to hurry, Mary was teaching the other nurses CPR for hypovolaemic shock during our efforts.

We called our “Walking Blood Bank,” which has been organized for over 15 years and is not a novel idea from some trauma center in the US, so that we could get fresh blood. It was her only hope. After three separate episodes of asystole with chest compressions and five units pushed in with the aid of some strong Kenyan hands squeezing the bags, the patient’s blood pressure began to normalize. We were now able to develop a plan to send her to our “quaint” five-bed ICU/PICU/NICU and give her the last bed available right next to our acute renal failure - an 18 year old Massai male patient. This young man had been given traditional soup advertised to “increase strength” two weeks earlier by the village healer, and now he was in renal failure which has a very high mortality in our area of Africa.

The maternal mortality rate of 1:16 in Sub-Saharan Africa is the highest in the world and the WHO estimates that 75% of these deaths were preventable. WHO estimates that over the next ten years, every two minutes one African mother will die in pregnancy, childbirth or within 6 weeks post delivery. As I waited in the PACU with Mary and this mother of two children for the ICU bed, I internally glowed with the pride of a teacher witnessing a former student perform to the level of their educational potential. In this situation, this anesthesia healthcare provider had prevented one of those Sub-Saharan African maternal deaths, which in itself is not newsworthy enough to merit CNN Headline News, but to her two children waiting for her at her village, this was the most important newsflash in their world.

Our second class of eight KRNA students represents four rural hospitals in Kenya which are very busy surgically. The clinical situation that Mary was required to navigate will be multiplied in the lives of these eight over the next few years. We have completed the Introductory Block, and now over the next twelve months they will be taught appropriate anesthesia skills and knowledge that will allow them to complete the program and decrease the 1:16 maternal mortality ratio, at least in their area of Kenya.

I am excited that the anesthesia books for the course arrived from London. Now, they have textbooks that will start their anesthesia library - a luxury for most students. I have already been asked to train nurses from Madagascar, Mozambique, Somalia, Sudan, and Tanzania in our next class which will start in late 2009. We are excited about the arrival of Vanderbilt Department of Anesthesiology residents coming in early 2009 both to help teach and to learn anesthesia in this international setting. They will be exposed to many aspects of anesthesia care which will allow their clinical skills to be sharpened and their global awareness of developing world health needs broadened which, we trust, will affect their entire medical careers.

I am sure this one mother who will now be available to care for her children will thank Mary for saving her life, since many of our patients want to know their doctors and nurses personally. The goals of VIA involve many areas of the world in the realm of anesthesia development and although the grandness of the vision is at times overwhelming, we need to remain focused on the one mother who was saved in Kenya. This enduring vision will allow the extra effort required to reach the goals which were established within the VIA Mission Statement and directly impact the maternal mortality statistics in East Africa.

Dr. Mark Newton
Kijabe, Kenya

 

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