One of the many challenges faced in the complex management of a surgical patient here in Kijabe is the post-operative period – the days and weeks after the operation in which the critical nature of a patient’s illness frequently manifests itself.  Whereas back at Vanderbilt there is an entire building filled with intensive care units containing hundreds of ventilators and innumerable critical care providers, here at Kijabe there are currently five ventilators available to adults and two to children. Before initiating an elective operation, the surgeon has to anticipate the post-operative condition of the patient to determine if he or she will need a bed and/or ventilator in the ICU. If this is not available, the operation is often postponed.  

Unfortunately, patients do not always present in an elective manner. Within general surgery, there were multiple occasions in which patients presented acutely with emergent need for an operation which could not be postponed. On one such occasion, at the conclusion of our procedure the patient was clearly critical ill and still needed support from a ventilator. However, none was available at that time. Therefore, after communicating this need to the ICU, our surgical team remained in the operating room for many hours as the ICU assessed which of their current patients could be ready to breathe on their own.  Six hours later the patient was transferred to the ICU for a breathing machine. 

This is a small example of the struggles encountered in providing the critical post-operative care needed here at Kijabe. For this same patient, on the fourth day after their operation her heart rate began to rise and she spiked a temperature. While in the U.S. a CT scan would have been promptly ordered, the patient and her family could not afford this. Therefore, we provided antibiotics and supportive care until she ultimately had to return to the OR the next day for exploration as her condition deteriorated. She is now recuperating but has sustained a very long hospital course.  

I realized promptly the amount of ancillary support and expensive tools I regularly utilize to take care of patients back in the U.S. If a patient is without nutrition after their operation, I can simply order nutrition to be given through their IV until their condition is appropriate to eat again. In contrast, here in Kijabe such nutrition is incredibly rare and expensive. Never before did I have to think about if a ventilator was available in the hospital or whether a family could afford additional imaging. Instead, I have returned to many of the basics: closely monitoring a patient’s abdominal exam throughout the day, speaking at length with the nursing staff about changes to vital signs or mental status, having honest conversations with families about quality of life and goals of care. In the midst of all of our technology in Western hospitals, we often forget these basics. I have learned the creative Kenyan solutions to many complex problems: using honey to promote wound healing, performing a complex abdominal wound closure with plastic zip ties, home-made tube feeding formulations. Kijabe has thus reminded me both to return to basics as well as to think creatively and outside the box during the course of taking care of the whole patient.