Jason Axt, MD
The next two weeks I found myself much better able to engage in the hospital system. Now I had learned the names of Benson, Mugo, Humphries all clinical officer or medical officer interns. It became my pleasure on night and weekend call to lead them through surgical triage or procedures. On subsequent calls I was able to help one of the medical officer interns through two chest tube placements. These patients had spontaneous pneumothoraces, but were not in extremis, thus I could take my time and coach the intern through the procedure. By the second placement, Mugo was able to anesthetize the patient appropriately, make the incision, and perform this life saving procedure. He remained a bit tentative, but I had seen vast improvement by this second time. These guys and gals are the front line of the Kenyan medical system, and are seeing patients in isolated places with no surgeons, or even residency trained physicians available. Teaching Mugo to place a chest tube well could benefit multiple Kenyan patients in the future.
We also had opportunity to entertain these learners in our home. We got to learn of some of the struggles they had to overcome. One resident commutes nearly an hour each morning and evening for the benefit of her family. Other interns come from extremely poor or difficult circumstances. The Kenyan health care system relies on these young men and women.
Another sad and challenging case that I encountered was that of D. He is 45 year old man who had been diagnosed with appendicitis over a month prior to my meeting him. He had been taken to theater for an appendectomy at an outlying hospital. When I met him he was post op day 2 and 3 from a second laparotomy for peritonitis and periappendiceal abscess. He had succus pouring from the lateral portion of a “hocky stick” incision. It seems he had been diagnosed with a post appendectomy abscess, and the medical officer (almost certainly not a surgeon) had encountered dense adhesions as he or she had attempted to drain this abscess. The operation had resulted in multiple enterotomies and now enterocutaneous (EC) fistulas. He likely had generalized peritonitis after his first operation or maybe at the time of his first operation. EC fistulas are difficult problems in the United States; here an EC fistula is devastating and likely fatal. We took him to theatre and did a diverting ostomy while closing or resecting the 5 enterotomies or anastomoses that had been left. We placed him on TPN – a rare and expensive resource here. We were unable to close his abdominal fascia, and settled for closing the skin.
He remains alive now 1 ½ weeks later. He remains on TPN after an episode of central line related sepsis and partial opening of his abdominal wound for infection. D. is an example of advanced surgical care done amidst quite austere and resource limited setting. He also is an example of a patient who would have fared much better with initial treatment by a well-trained surgeon. Simple ultrasound guided abscess drainage could have avoided this morbid procedure in this patient, but is available here in a limited fashion. D. remains very grateful for his care and is asking the hospital clergy and medical staff to pray with him and for him. Surgery in Kenya is far different from that at home. Learning to work and teach amidst the resource constraints here has been a stretching and eye opening experience.