I’ve been in Kijabe a little over three weeks. Yesterday I attended a special morbidity and mortality conference wherein we reviewed the preventable death of an orthopedic trauma patient. I was peripherally involved in his care and of course have repeatedly questioned myself about whether or not I could have should have predicted picked up on followed up on any number of details that were put together only too close to the time of his death. I sat through the discussion partially numb while so many glaring systems issues that contributed to this outcome reached out and slapped me in the face.
 
Quality improvement work is so cut and dried when presented as an academic topic – root cause analyses, PDSA cycles, systems-level reflection following carefully laid-out evidenced-based models with neat acronyms. But the sensitive nature of debriefing a bad outcome and preventing future similar ones is always messy. It takes more than an hour, and hinges on mutual respect and established relationships. I’ve been struck by the willingness of the staff here at Kijabe Hospital to discuss bad outcomes openly and often. It’s necessary. Complications happen everywhere, but talking about them is the first step.
 
Next week I return to Vanderbilt. Some of the resources I most look forward to include:
  1. Ubiquity of dressing supplies – no need to ask patients to purchase each piece of gauze from the pharmacy before dressing their wounds in clinic or the ward
  2. Medical receptionists – to avoid the frustrating experience of locating patients in the gray areas between the ER, outpatient clinics, waiting areas, and hospital wards without an up-to-date directory of patient location
  3. A serviceable EMR
  4. WiFi – for ready access to UpToDate, PubMed, society guidelines, etc.
  5. Nephrologists, gastroenterologists, interventional radiologists, all radiologists, psychiatrists, and all my other specialist friends not represented here
In contrast, things I will miss about my time in Kijabe:
  1. Teaching junior residents here
  2. A more relaxed surgical hierarchy
  3. The option of not pan-CT scanning every acute and elective surgical patient
  4. Reusable sterilized cloth drapes and gowns in the OR
  5. The simplicity of hanging IV fluids on a nail on the wall behind a patient’s bed
  6. Being a 5-minute walk from the hospital while on home call
  7. Taking time to greet everyone good morning before getting “down to business”
Health care is notoriously expensive in the U.S., but rarely in my general surgical training have my patients had to grapple so viscerally with the financial implications of their illnesses in the acute setting. In Kijabe, I see this play out daily. The pedestrian hit by a matatu who is so preoccupied with his emergency room bill that he is unable to concentrate on our physical exam to diagnose his pelvic fracture. The septic newly diagnosed diabetic man with a massive back abscess who spends the night in the clinic waiting room instead of upstairs in the ICU because he doesn’t yet have the deposit for his hospital admission fees. The fresh motorbike trauma patient with abdominal pain and potentially undiagnosed solid organ injury who leaves our ER against medical advice for another facility where she believes CT scans to be less expensive. The elderly woman with dysphagia and biopsy-proven esophageal cancer who delays getting a staging CT scan or endoscopic stent placement for months or even years while her family crowd-funds the next step in her care. Maybe my patients in the U.S. are making similar life-or-death decisions based on financial calculations, but it doesn’t happen in front of me.  
The National Health Insurance Fund (NHIF) started about 4 years ago to offer free insurance coverage to all Kenyan citizens. Kijabe Hospital fees are out of reach for >70% of the population, so NHIF coverage is critical to the hospital’s mission of caring for patients while remaining financially viable and sustainable. In recent weeks, NHIF abruptly stopped covering surgeries and maternity fees at mission hospitals across the country, including Kijabe. This crisis has translated into lower surgical case volumes, fewer training opportunities for my Kenyan resident counterparts (i.e., the next generation of surgeons in East Africa), and a growing number of patients not getting the operations they need in time. Watsi, an international crowd-funding platform, and Friends of Kijabe (https://friendsofkijabe.org/) are two ways people can help.
 
Costs affect patient outcomes in innumerable ways. Approximately 40% of breast cancer patients cared for at Kijabe are HER2+ and would receive a survival benefit from a targeted course of Herceptin therapy.  Yet at a cost of $27,000, this treatment is out of nearly everyone’s reach. For comparison, in the nearby city of Naivasha, most of the local population works for a company that produces fresh-cut roses for the European market. They make $70 per month. A recent Lancet Commission on global surgery determined that 25% of people who have a surgical procedure incur financial catastrophe as a result of seeking care – although this proportion is probably far higher in Kenya.  
 
For the past seven years, I have lived the daily luxury of not thinking about costs for 99.99% of my medical decisions. The luxury of doing the right thing for patients, regardless of cost implications or their ability to pay. Is this wrong?
I have just wrapped up another exciting and challenging week 2 and 3 at Cape Coast Teaching Hospital (CCTH). I have started providing once a week outpatient echocardiographic imaging for the hospital besides providing free heart imaging for several children and adults who are inpatient. The two internal medicine residents who are training in the focused echo imaging are making significant progress. Getting and echocardiogram is difficult and expensive in Ghana. It cost $80 - $100 to get an echo done and sometimes one has to travel to the capital city which is 3 hours away. So far together with the trainees we have provided free cardiac imaging for nearly 80 patients for the past 3 weeks. One pediatrician has also started training for focused echo this week. I am looking forward to the first of 3 evaluations for the trainees in week 4.
I have just completed my first week at the Cape Coast Teaching Hospital, Ghana and have started week 2. It has been an interesting experience so far. My travel to Ghana was uneventful. My first day was very busy and started with echocardiogram of a Man with pulmonary tuberculosis and heart failure. Given that I have a handheld echo machine it was easy to image him at the emergency unit. I took the opportunity to start teaching the two providers who are participating in the focused echocardiogram training. The hospital has a standard echo machine but have no providers to do echocardiograms, so this training will be extremely beneficial to the hospital and the patient population they serve. The CEO wants me to set aside one day a week to provide echocardiogram service for outpatients. I will continue to perform inpatient echocardiograms with the current two trainees every day throughout my stay.
Frist Global Health Leaders: Taylor Matherly – Weeks 3 & 4 in Quetzaltenango

Over the past couple of weeks, I’ve continued my engagement with Primeros Pasos’ Nutrition Recuperation Program. In addition to administering the surveys developed during my first two weeks here, I’ve also begun leading “charlas” (chats) alongside Primeros Pasos’ nutrition outreach coordinator, Monica. These charlas are designed specifically for mothers of school-aged children who have been identified as being either malnourished, underweight, stunted, or overweight. Charlas are held monthly in each target community, of which there are four in total.
My two-month Masters of Public Health practicum placement with Primeros Pasos in Quetzaltenango, Guatemala started off on a dramatic and tragic note. Upon exiting Guatemala City’s La Aurora Airport, I immediately noticed an odd-textured rain falling down on me while I waited for a taxi to transport me to one of the city’s many bus terminals. Also noticeable was an intense smoky smell and texture of the air, which I at first attributed to air pollution. Once I arrived at the bus terminal, the bus driver urgently shepherded everyone waiting around onto the bus, informing us that the nearby volcano named “Fuego”, Spanish for “fire”, had had a major eruption. In order for the bus to get to its final destination of Quetzaltenango, it was necessary to first drive towards the volcano before passing it for higher ground in the Guatemalan highlands. Traffic, sirens, and noticeably thick and discolored air were a constant until we had traveled for about two hours north. It was at this point that my fellow passengers and I overcame our initial panic enough to realize that we all had what we now knew was volcanic ash coating our hair and clothes. After the strange “rain” had settled and dried, it had a sand-like consistency and a dark-black appearance.
Thoughts from a remote village in Kenya.

I remember more than 15 years ago before I started medical school, I attended a small global surgery seminar where several residents and invited speakers introduced the community to global surgery and the needs of health care in third world countries. The night started with a surgical resident saying the following statement “hospitals in third world countries are places where people go to die, not get better”. I still remember my reaction and how infuriated I was with such statement. I was born and raised in Colombia, South America and thought about all the times I had been sick, taken to the hospital, and here I was, alive! I had been inspired in the same hospitals to become a doctor, help people and save lives.
It is hard to believe this trip is coming to a close! A lot has happened since my last post. We traveled to Siem Reap and experienced the beautiful ancient temples including Angkor Wat and Angkor Thom. These temples left me speechless. Truly marvelous to think they were built in the 12th century by nothing more than elephants and man power!
Jambo from Nairobi!!

We are currently sitting in the Nairobi airport at the conclusion of an amazing, eye-opening, and life-changing trip.

Our week started out with a bang! We were on ICU call Sunday, but Dr. Newton was so kind and covered the unit after rounds so that we could explore. We drove out to Mount Longonot for a day hike and did not know what we had gotten ourselves into! The hike up was a challenge, since many of the trails had been washed out from all of the rain this season. However, once we made it to the top, it was all worth it. The views from the crater were absolutely breathtaking!
Week 3: By week number three we felt comfortable in Cambodia; we were starting to pick up on some of the language; we were making new friends…. But we were also starting to feel a little bit home sick. But by the time we departed, I can honestly say I was sad to go back to our materialistic lives in America. I cannot WAIT to have the opportunity to go on another mission trip.

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