For my recent birthday, Allison invited a few people for coffee and sweets on a Sunday afternoon. I was glad to spend some time with a lot of good people, and I was especially glad to spend time with the Kijabe Hospital Internal Medicine team. We have a great group of American and Kenyan doctors working together to take care of the complex medical cases in the medicine wards, the intensive care unit, and the COVID ward. We deal with a lot of tough cases and some really desperate situations, but there is not a day that goes by without this group giving me something to laugh and smile about.
I am back in a normal hospital ward for a change, and it feels so relaxed in comparison to the weeks I have spent in the ICU and in the COVID wards. It turns out this is the week of ascites and liver failure. I do not recall ever having so many patients with liver failure at the same time in Kijabe. Alcoholism, Hepatitis A, and still to be diagnosed causes for liver failure fill the wards. I have been opening my computer and looking up possibilities for liver failure and ascites to try and solidify diagnosis. In addition heart failure, intestinal bleeding, and bone infections round out the service.
I am glad to be on the wards, because we have more clinical officer interns and medical officer interns present to know and to train. Frequently I find myself pushed to improve through their questions. This week I am working with one specific intern who begins many of his questions with the phrase “with all due respect”. When I hear that at the beginning of a question, I know that I have possibly missed something and that my intern is feeling pretty secure in questioning a treatment plan. This intern has me on my toes, and it is good. He makes me look into why I am doing some treatments in the manner I am doing them. Have I gotten a little relaxed in a resource limited setting? Am I still pushing for excellence in the care of our patients? He knows what the book says, and he wants to know why what we do does not always match the guidelines. Often there are reasons that are sound because of the financial and logistical constraints of the hospital, but other times I am left with the thought that I should be pushing harder for increased levels of care. In this way it is a good push, despite the discomfort of being questioned. Even as I sit typing the post, I am wondering if all of the internal medicine consultants should get together to see if we should go over our guidelines again to see if we can become less constrained by our resources and push for less limitations in our ambitions.
This is from the Samaratin’s Purse website.
Mission Organization: Africa Inland Mission (AIM)/Africa Inland Church (AIC)
Profile: Kijabe Mission Station was first established by missionaries from AIM as an outpost in 1903. The first hospital at Kijabe, Theodora Hospital, was established in 1915. This served the medical needs of the area until the present complex was begun. The first building of the present complex was opened in 1961.
Today, Kijabe Hospital is a non-profit, 363-bed hospital owned and operated by AIC of Kenya as part of a network of four hospitals and 45 dispensaries. It employs over 900 staff and strives to balance Kenyan and missionary consultants. The hospital offers a broad range of inpatient and outpatient curative services to people from the surrounding farming communities. The hospital includes five inpatient wards (general surgery, medicine for adults and children, obstetrics and gynecology, neonatal care, and rehabilitation), nine operating rooms, an outpatient clinic and 24-hour casualty department, an eye clinic, and a full-service dental facility. Support services include a clinical laboratory, a fully equipped pathology department, X-ray, ultrasound, electrocardiogram, pharmacy, physiotherapy, and central medical supply. Kijabe’s laboratory offers immunohematology, hematology, biochemistry, parasitology, urinalysis, bacteriology, and blood banking services.
The pathology department provides tissue diagnostic services to 37 mission hospitals in East Africa. The OPD provides services for general acute illness as well as specialty clinics in diabetes, orthopedics, rehabilitation, ophthalmology, TB, gynecology, high risk pediatrics, and AIDS. Malaria, pneumonia, TB, tropical diseases, and AIDS are common diagnoses. A Maternal-Child Health Centre (MCH) within the hospital provides antenatal care, family planning, and childhood immunizations. Kijabe also sends mobile health teams to 12 villages each month to provide these same services.
Kijabe is a general hospital and performs more than 200 operations each month. In past years, the most commonly performed operations have included: C-section, tubal ligation, exploratory laparotomy (non-trauma), skin graft, supra-pubic protatectomy, D&C, hysterectomy, ORIF femur fracture, salpingectomy (ectopic PG), sequestrectomy (osteomyelitis), and removal of various cancerous tumors. A dental department was begun in 1978 as a satellite clinic of the main AIM dental clinic in Nairobi. The hospital also trains nurses and medical students and has Community Health Evangelism (CHE) and chaplaincy programs. Because people know they can receive quality care at Kijabe, many are willing to wait weeks or months for their procedures. Bed occupancy averages 80 percent.
Travel: Fly by commercial airline to Nairobi; drive approximately one hour to Kijabe (6 km down a steep, winding, narrow but paved road off the main Nairobi/Nakuru highway). Time Difference +7 hours Daylight Savings Time (EST), U.S.A.; +8 hours Eastern Standard Time, U.S.A.
Location: Kijabe Hospital is located about 60 km north of Nairobi. The altitude is 7,200 feet up on the edge of an escarpment overlooking the Great Rift Valley which extends from the Sea of Galilee to Zimbabwe. People The largest group of people served by Kijabe Hospital are the Kikuyus, although the number of Masai patients has recently increased.
Language: Swahili and English are the official languages of Kenya although local tribal dialects are also spoken. All medical staff speak English fluently, and nurses provide translation to Swahili or Kikuyu. Medical records are written in English.
Religion: The population is primarily Christian (Protestant and Catholic), although some of the more remote tribes practice animism and spirit worship. Muslims and Hindus comprise a smaller portion of the religious community.
Climate: Kijabe is a Masai word meaning “Place of the Winds.” Although strong winds are common, there are periods of calm on most days. The high altitude makes for generally pleasant days (about 80°F) and cool, windy nights (about 55°F). There are two rainy seasons in March–June and October–December. June–August can be quite cool and December–March is typically dry and hot. There can be a lot of mud in the rainy seasons. June––August can be quite cool. December–March is the driest and hottest season.
Housing: Housing is in modern, comfortable homes, duplexes, or apartments which have kitchen equipment, hot water, and electricity. The housing is simply furnished, secure, and near the hospital. Daily housing costs cover electricity, water, security, appliances, and furniture. The Pathology Department has its own apartment for visiting and/or resident pathologists.
Food: Meals are not provided at the hospital so be prepared to buy your own food and prepare your own meals. Most basic items (including fresh foods) that are available in U.S. grocery stores can be found in Nairobi. For More Information Contact Mackenzie Welde by email or by phone at: (828) 278-1371.
We appear to be finishing our third wave of COVID infections in Kenya. I am rounding on the COVID ward this week, and while we started the week with every bed full, as the week has progressed we have decreased our census. The way the COVID ward works is that any patient who comes to the hospital with low oxygen levels, cough, shortness of breath . . . basically any sign of respiratory disease . . . will be sent to the COVID ward clinic, or if they are sick enough they go to the COVID emergency room. When I am working in the COVID ward I cover the COVID ER, the COVID wards, and the COVID ICU. I take care of patients who have COVID pneumonia (not that many currently), but I also have the task to figure out who actually has another disease such as heart failure or some other issue that can look like a COVID but is not. We assess them, and if we determine they do not likely have a coronavirus infection we send them to other parts of the hospital to receive more appropriate care. This week has been a good week. In the past everyone looked like COVID. Now most look like something else and I have been able to move them out of the COVID ward. It is a real relief.
Unfortunately, our fourth wave is predicted for July. We are all praying that despite not having many vaccines in Kenya, that maybe we will avoid the fourth wave.
What does medical education look like? Let me describe today.
I was up early for some reason, eyes open at 4:30 AM. I have been getting up early this week . . . but 4:30 is about an hour earlier than usual. So after showering and some reflective time and Bible reading, I started reviewing my notes for today’s lecture on shock and sepsis. This review was an ongoing process while waking up the kids multiple times until they are out of bed, and then seeing them off to school. I went into the hospital around 8:30 AM, quickly walked through the ER and the two step down ICU units, finally ending my walk in the ICU. I wanted to see who had been admitted overnight. Around 9:00 AM as I was reviewing my patient’s labs and x-rays while also updating our audit sheets, I was called by the ER doctor that he had just intubated a young woman in the ER and was sending her to the COVID ward. He wondered if I was covering COVID. I told him I was in ICU, but that I could help in the COVID ICU if needed. One of our medical officers is covering the COVID ward this week, and I am her back up for complicated patients. I decide to run down to the COVID ward to meet the patient on arrival. Unfortunately, the patient was not there yet, but I spent the opportunity to review antibiotics, ventilator settings, and plan of care with the care team in the ward. This was an unplanned teaching moment, but it was a typical educational opportunity at Kijabe. We teach at the moment of giving care or preparing to give care. Not all the interns or medical officers are comfortable with the ventilator, and reviewing the machine is a good chance to teach about how the lungs work, how the body balances acid and base levels, how circulation functions in different pressure scenarios, and how to think logically about the process.
While there, I got a call from the gynecological team for help with a patient. I was just across the courtyard, and so I ran over and gave a mini-lesson how to manage inpatient blood sugar levels and how to start insulin on a new diabetic patient. That was my second unplanned teaching moment of this still early day. Since the patient had still not arrived to the COVID ward, I ran upstairs to round with the ICU team. My trainees are muslim and Christian, and it is a good chance to try and model Christian medical ethics to all of them. This was my first scheduled teaching time. We had several new patients admitted overnight to meet and several previously admitted patients to review. With each patient there is a new topic to cover. Diabetic Ketoacidosis, tuberculosis, meningitis and renal failure in one bed. An epidural hematoma in the next. A hemothorax and multiple trauma injuries suffered by our next patient. The fourth bed is an HIV patient with a cheek tumor. Then we went on to the two HDU’s to discuss hyponatremia, seizure disorder, stomach hemorrhage, and stroke among many other things. After rounds, I ran down again to the COVID ward to discuss the new admission. We reviewed her chest x-ray, the possibilities diagnosis that she might have and how we were going to sort them out. Again I did a quick review of ventilators. This is another great chance to try and teach. I went back up to the ICU, and as I was reviewing some other patients I get a call that the woman in COVID ward is needing resuscitation. So we spent 40 minutes trying to save this patient, and through it all we are reviewing the rules of Advanced Cardiac Life Support and Basic Life Support. We got some labs back that show she is in complete renal failure, and so we spoke a bit about that. We teach while treating patients. Then I was tasked with informing her husband about her passing, and I did that with one of our interns. This is different, but it another form of education. It is a chance to model Christian compassion while breaking bad news.
I quickly ran home for some lunch, then, as there was a small break in the rain, I ran back to the hospital. Now it was a formal teaching time, and I reviewed for one hour sepsis and shock with the interns assigned to the ICU. Afterward, I received two calls from my medical officers, reviewing patients with them. More informal teaching. The afternoon exit rounds were spent reviewing a man who had been in a car accident in whom we found a diaphragmatic rupture on CT that we ordered in the morning. I spent another 30 minutes going over all of his x–rays and CTs trying to see if there was a way it could have been found earlier. That was a learning time for me, trying to get better. And I hope it models a certain humility and need to always try and get better to our interns.
That is how teaching works in a teaching hospital, and specifically at Kijabe Mission Hospital. Formal times mixed in with many random opportunities. I learn each day, and I try and pass on how I learn and what I learn to those interns who entrust their education to us.
Today, after multiple attempts, Allison and the kids flew out to Dallas toward Nairobi. Allison received her tourist visa this morning, and so we got up early and had the tickets changed and put everyone but me on a plane today at 3PM. I am so glad for them. It allows them to avoid sitting in a 2 week quarantine in Kijabe before they could attend school in person. So tomorrow around noon our time in Dallas, Allison and the kids should be landing in Nairobi. Yeah!
I walked the long way into work (its not long really) because we have closed off all but two entrances into the hospital so that all can be temperature screened before entering. It is nice to enjoy the very brisk morning air, watch the monkeys, and listen to a podcast.
8:30 AM Time for the weekly audit of mortalities and close calls on the internal medicine service. This week a lot of time was spent discussing the COVID ward and some ICU complications from the past week. At the end I got a nice despedida with a coffee mug that I had been hoping to get with the Kijabe Hospital logo.
10:00 AM Rounds in the ICU. In the last 2 days we have added 8 new patients. Yesterday was worse when I had six new patients in the span of just a few hours. Today it is just two new patients. Severe hyponatremia, a patient with a adrenalectomy in whom we have to closely watch the potassium and blood pressure, a myasthenia gravis with mucus plugging causing one lung to not function well (she got a tracheostomy yesterday), a traffic accident with a broken hip and ribs, status epilepticus, sepsis in a patient with esophageal cancer, another who has had her right shoulder and arm removed for cancer complications, severe diabetic ketoacidosis and sepsis . . . the list goes on!
12:30 Time to do some record keeping of the patient for the last week so that we have good records of what they presented with, how they did, how long they were in the hospital. We do this to see trends in our care and illness and improve quality over time.
2:00 No lunch today. It made me wish I had eaten breakfast. The coffee from the morning was serving me well. Time to teach EKG reading to my trainees. One is an orthopedic resident. The other is a medical intern (1st year out of medical school). They have been with me all week on the ICU service.
3:30 Afternoon rounds on all the patients from the morning to see how they have progressed. Everyone seems to be ok, although many are still sick. Several are well enough to leave the ICU.
4:15 I get a call from one of my ECCCOs (ICU clinical officer) stating there is a problem in one of the HDU (like an ICU but without a ventilator). One of the surgical patients we have been rounding on who had major spinal surgery now has a heart rate of 200! This is new to us. An EKG is ordered. She is stable, and I take the moment of getting the EKG to take Dr. Steve on rounds of all the patient in the ICU service. Steve is on call tonight, and I confess I am relieved that he can take the lead on dealing with the tachycardic patient. Is it a sinus tachycardia or atrial fibrillation with rapid ventricular response. Hopefully the EKG give him some clues.
5:00 Steve is in charge. I leave notes on all the patients for the weekend coverage doctor, and head home to start packing for my flight on Saturday. A pretty full day for my final ICU day for awhile.
Being at Kijabe has to be one of the best jobs in the world!
I spend a lot of my time doing schedules. I “get” the pleasure of creating the weekly assignment for the internal medicine service as well as the call schedule for the internal medicine service, the outpatient department, and the COVID-19 ward. We are in tough times at the hospital. No volunteers, many of us leaving for our home countries. Staffing is short, and I try my best to be sure everyone gets some time off at some point. Everyone needs a break at times, no matter how much you feel called to the work or even love the work. So please pray for the endurance of the staff at Kijabe Mission Hospital. We are going to need a God-given strength to do the work he has put before us, especially as the COVID virus becomes more severe. God bless Kijabe Mission Hospital.