My International Rotation Experience in Kenya
By Richard Vest
October 24, 2005
Kiplangat smiled as I walked to the edge of his bed. Even though he could not talk, he had big news to tell me today. His enthusiasm for life was evident in his big, yearning brown eyes, and it hid the difficulty of his present hospitalization. Only 16 years old, Kiplangat had rheumatic heart disease (RHD), and his heart valves did not function properly as a result. His family had brought him to "Casualty," the Kenyan name for ER, at Tenwek Hospital near Bomet , Kenya . On arrival he was very sleepy and could not speak or move the right side of his body. He had some swelling in his legs, a sign that his heart was not pumping efficiently. I could hear loud murmurs when listening to his heart, and I realized that I had never seen RHD in a young person in the USA . Kiplangat seemed to have had a stroke from a clot which formed on one of his heart valves and then flowed to his brain. CT and MRI scans were not available, so the diagnosis had to be made upon physical exam alone.
To an American-trained physician this case seems most unusual. But it was only one of numerous medical cases which had been foreign to me prior to my travels in Kenya . During the beginning of my senior year of internal medicine residency I had the unique opportunity to work for 2 months at Tenwek Missionary Hospital near Bomet Kenya . Although I had traveled abroad in the past, I had never spent that long in a third-world country. I had certainly never worked as a physician in Africa .
My wife and I lived in a comfortable 2-bedroom apartment on the Tenwek "compound," about 2 blocks away from the main hospital. I was considered an internal medicine attending physician at Tenwek and had the associated responsibilities. The 300-bed hospital has 4 main departments: medicine, surgery, obstectrics, and pediatrics. The internal medicine service has two of its own wards, actually two large rooms: men's and women's. Some medicine patients are also cared for in the ICU, a unit shared by all specialties. The male and female medical wards each has 17 single beds, but each ward may have up to 30 patients as bed-sharing is not unusual.
Resources are considered precious at Tenwek, and supplies often considered disposable in the US are often reused in Kenya . Oxygen is available at about half of the beds in medical wards, and long tubing hung across the room can be used to provide oxygen to additional patients. Spinal fluid is collected in glass tubes with rubber stoppers, and these are sterilized and recycled for future use. This contrasts with disposable plastic tubes used in the US . Rather than being dictated discharge summaries are hand written with a carbon copy sheet between two pieces of paper. One copy is given to the patient at time of discharge and the other goes in his or her file.
My typical day began with morning report. Kenyan interns who had been on call the previous night would present the patients they had admitted to attendings, fellow interns, and medical students. I was used to being the one presenting cases in the US , so it was great to be presented to and get to be a part of the teaching. Rounds would begin after morning report, and they were often frenzied. As the internal medicine attending, I was responsible for as many as forty-five patients in a given day, but I typically had two Kenyan interns and one or two medical students who were part of the team. Despite the volume of patients, I had many opportunities to share in the spiritual lives of my patients, sometimes praying with them. The wards often had many young patients 15-40 years old, and this was quite a contrast to US wards which mostly have elderly patients. Most of the younger patients had advanced HIV and AIDS-defining illnesses. Common illnesses included bacterial meningitis, Cryptoccocal meningitis, TB meningitis (presumed), rheumatic heart disease, heart failure, malaria, typhoid, pneumonia, empyema, and disseminated TB in a variety of forms. Brucellosis, leishmaniasis, lymphatic filariasis, and leprosy are seen less often.
Patients were seen with the assistance of a translator, sometimes making rounds inefficient and lengthy. The physical exam was crucial as X-ray and crude ultrasound were available but no CT or MRI scans. Common labs were available, but one had to order individual chemistries, such as sodium or potassium, rather than a standard "chem7." Prioritizing tests was vital as patients had to pay out of pocket for each test ordered. The constant question I asked was, "Will the results of this test change how I care for the patient?" If not, then the test was not ordered.
Organization could be quite a challenge as patients seemed to change beds constantly. I kept a hand-written piece of paper with each patient's name, bed number, essential medical data, and a to-do list for the day. This helped me keep track of the many patients as well allowed me to remind students and interns of procedures or labs which needed to be done. But each morning the patients would be in different beds, thus making my hand-written patient list very confusing! I leaned that some patients had to be moved to be closer to an oxygen outlet in the wall, while others who had to share a single bed found they preferred a different bed partner who perhaps was not vomiting or soaking the bed with sweat from high fevers.
Afternoons were spent helping students with procedures, following up studies, and performing internal medicine consults. The days could be long, and I often left the hospital late into the evening. Leaving the hospital was always difficult because the work never seemed to be completely done, and Casualty seemed to always have another patient for the medical wards.
I did "take call," but it was not difficult as it was considered attending call. I could stay at home and would get called by the intern on call with each new admission. Usually we could discuss the case over the phone, but I would walk to the hospital if the patient was very ill or the intern needed help.
I did not expect Kiplangat to get better, but he proved me wrong. Despite developing pneumonia, he had progressively improved. His exciting news was that for the first time in a couple of weeks, he had taken a few steps! He still could not speak, but he laughed when I gently poked his stomach to get an audible response. Kiplangat's family came each day to see him, and his younger brothers and sisters would eat whatever food he didn't from his metal bowl. The menu was almost always the same: boiled cabbage and ughali (a type of mashed maize) or red beans and rice, sometimes with a special treat of half an orange. Kiplangat continued to improve, and one week later he walked home with his family under his own strength. He never was able to speak before leaving the hospital, but his bright eyes and huge grin spoke volumes to me.
I left Kenya a different person, with a list of questions which replayed in my mind. What things are truly important in life? Most Americans would consider the Bomet area very poor, but most of the Kenyans are quite content as they have food and shelter-even if it is a mud hut. I did not leave with a sense of pity for the culture, as most Kenyans care more about relationships with family and friends than the possessions they could have. At the end of the trip my wife and I found ourselves sitting on the Kenyan coast watching a man catch fish from a hand-made, dug-out canoe and push himself through the Indian Ocean with a long stick. She commented, "Being half way around the world and seeing the things we've seen, the clothes, fashions, entertainment, and social status just don't seem very important right now!" My first day back to work in the US was a shock. The hallways seemed packed with doctors in a frenzy to get to the office. Some walked as if they had been called to a patient who was dying, but I knew they were actually in a hurry to get another article published in a well-known journal or submit a research grant. My critical attitude was quickly curbed, however, when I realized I was seeing a reflection of myself.
Next summer I'll begin a lengthy fellowship in general cardiology, clinical research and epidemiology, and eventually cardiac electrophysiology. I hope to publish many articles in important journals and become a masterful clinician, but I hope this won't be the most important thing in my life. I hope I'll remember Kiplangat and the hospital of the young. I hope I'll remember the relationship-focused Kenyans and work as hard at being a loving husband and father as I do to become a successful academician. I hope I'll share my Faith with my patients and pray with them when invited.
I already look forward to the next medical trip I'll take to an international destination. The second most frequent cause of death at Tenwek is heart failure, so perhaps my training in cardiology will be a unique tool which can be used in international hospitals. I might be able to perform echocardiograms on patients with valvular heart disease or provide cardiac procedures which are typically not available. I hope I'll be able to make an impact on a culture which has enormous health care needs, but even in advance I know the biggest impact felt will be the culture's influence on me.
Richard is an Internal Medicine Resident at Duke. He visited Tenwek Hospital , Bomet , Kenya , East Africa this past summer.