It was only thirty minutes after arriving back in Kenya that we heard a familiar knock on our aged wooden door that has hinges from the colonial era of East Africa. Alerting us that we would need to postpone the unpacking of one of our 16 bags (five were missing), we were thrust back into life in Kijabe, Kenya, which has been our home for eight years. Grace’s swollen face full of rotting teeth ushered us quickly back to the reality of our work in Africa and far from our time this last year in the United States. We left for a year, but Grace’s HIV kept destroying her body so that now she has full blown AIDS. Although we will miss Smoothie King, Subway, and most of all the YMCA, we know that we are needed here as much as ever.
As part of Vanderbilt International Anesthesia (VIA), we have returned to restart the Kenya Registered Nurse Anesthesia (KRNA) Program where we will train nurses in the area of anesthesia care for rural Kenya. These first two weeks, we have placed electricity surge protectors in our cinder block, tin-roofed home to protect our computers; purchased a large, four-wheel drive vehicle since the largest vehicle at the intersection has the right of way; rediscovered the mangos, papayas, and bananas of this equatorial region of the world; and watched our five children explode with joy as they greeted their African friends. The KRNAs have been performing well without much supervision with patients with advanced pathology and limited resources, and they are excited to prepare for the second class of students.
My first emergency case back in Kijabe allowed me to compare my current situation with the last 12 months at Vanderbilt Children’s Hospital. The patient was a 6-hour-old little Maasai girl born to a 23-year-old mother with no prenatal care. After laboring for over 24 hours in her mud-walled home about 1.5 hours from Kijabe, she was carried in the back of a truck following an animal-trodden, dusty, roller-coaster road to find out after the C-section that she had a child with an omphalocele. We placed the monitors (we only had adult-sized ECG pads), and after a dose of thiopental and succinylcholine, I was told that the halothane vaporizer can only be turned to 0.2% and after seeing the gas analyzer I understood. The KRNA told me that this “new,” donated anesthesia machine had a “bad” vaporizer that resulted in a cardiac arrest in the first patient due to overdose, and at 0.2 % the reading was 2%. We have the one person in the country that will come to the hospital to calibrate the vaporizer scheduled to come in the next two weeks. Once we found the one mask small enough to fit the face, the surgery was a success with a spontaneous breathing patient, no narcotics, local anesthetic, only the skin closed since a closure of the fascia would cause many physiological changes that could not be handled post-op, and an extubated patient 15 minutes after skin closure.
This last weekend, as the only anesthesiologist for this 210-bed hospital, I was called in for an ICU patient who had just arrived from a large refugee camp with 170,000 people and poor medical care. She needed a subclavian central line that was placed using three sets of donated supplies to get the necessary items. Then after resuscitation over a few hours, she was taken to the “operating theatre” for an amputation. She seemed to have had an arterial thrombosis seven days earlier and one day earlier, we had a team of physicians visiting the camp and examined this 35-year-old female. She had poor femoral pulses, and she was in septic shock with only dopamine in a buretrol affording us the luxury of a blood pressure. I forgot to mention that we do not have any ephedrine in the entire country because “people are using ephedrine to make back street drugs.” This patient once again demonstrated the poor state of medical care for many in this part of Africa who are in extreme poverty and suffer more than most of us could ever imagine. I was feeling good about the anesthetic management and while I was getting my flashlight ready to walk down the five-minute trail to my house, I was again thrust back into my anesthesia world and the reality of living in a place so different from Vanderbilt.
I was reminded by the Kenyan nurse: “Did you hear that they have spotted a leopard around your old house, and it killed two dogs two nights ago?” As I was searching the trees of the path that was less than 400 yards from my “old” house on my journey home in the darkness of a half-moon night, I was amusing myself with the thought that I could add to the base points for billing in the US if I mentioned that the ASA status had to be elevated due to the added acuity of a “leopard spotting.”
These are all true stories that describe in broad strokes the life of an anesthesiologist and his family working in a hospital in Kenya, September 2008. We send our greetings to everyone at VCH and the Department of Anesthesiology at VUMC.
Dr. Mark Newton