December 14th, 2019 by Daniel Russo

Late entry. Written 12/12/19

Happy Jamhuri (Kenyan Independence) Day! Today Elaina and I are on call for the wards but it has been a quiet day so far. We were called in for a couple admissions but have otherwise spent the holiday walking around the compound, purchasing souvenirs from local shops, and reading. Since I finally have some time to blog here is a recap of the week so far:

Since our return to work after the safari, Elaina and I have both been working in the outpatient setting. Initially she was working in the OPD (what they call their outpatient clinic for patients age 7 and up), and I was working in outpatient pediatrics. However, while the OPD is very busy, the outpatient pediatric unit is somewhat slow and I was working as the consultant for 3 providers (a CO, CO intern, and MO intern). This basically means I was waiting in the hallway to precept patients if they had any questions—and they don’t have many as they are all fairly experienced. There have been a few interesting cases I was called in “to review,” including a 6 month old with a large hemangioma involving the lower lip and jaw, and a 3 month old boy with an imperforate anus who had had a colostomy placed shortly after birth at an outside hospital close to home. The parents then brought him from over 900 km away for colostomy reversal, as they had heard the reputation of the pediatric surgery team here.

Since the outpatient pediatric providers seldom had questions, I gave them my phone number to call with issues and joined Elaina at the OPD. The OPD is run as a walk-in clinic. Patients arrive early in the morning, are entered into the computer system in the order of arrival and then are seen in that order (unless they are in extremis). The OPD staffing is tight so luckily there are enough English-speaking patients to be seen that we do not need to pull anyone to be a translator. Elaina and I work together in a room alternating interviewing and examining the patient and recording on the electronic medical record they have (which can be a little slow and crashes the computer occasionally). Again, patients seem to come from all over the country as well as from Somalia and Ethiopia to receive care here. Some of the outpatient complaints we have taken care of over the last few days include COPD exacerbation, goiter, back pain, plantar fasciitis, as well as patients returning for routine follow up visits and med refills for chronic diseases such as hypertension and lipid disorders.

One particularly memorable patient from this week was a middle-aged man with known HIV+ status (they use alternative acronyms like RVP or PITP due to stigma) who had previously been treated for cryptococcal meningitis (which seems to be a diagnosis we run into daily here) earlier in the year. He had symptoms concerning for a possible recurrence so we decided that he needed a lumbar puncture to measure the pressure of his CSF as well as test the fluid for various infections including a CRAG to test for Cryptococcus. This case taught us a lot about the “business side” of medicine here in Kenya. First there was a discussion of whether we should transfer the patient from the general outpatient ward to the “casualty unit” (what they call the ED). This would mean he would incur a bill from both OPD and casualty so we opted to do the tap first in OPD and then if needed directly admit to the ward and bypass casualty. Then we had to place an order for the supplies needed to do the LP: an LP kit, spinal needle, gauze, dressing kit, and sterile gloves. Then the patient had to leave the OPD area to go to the cashier and pay for all of the supplies (including the gloves and gauze). His receipt was then given to the supply office who dispensed the needed supplies. Unfortunately, the labs to be performed on the CSF had not been ordered at that point so after they were ordered the patient again had to stand in line at the cashier to pay for the tests before we could perform the LP. We finally had everything ready and performed the LP with the help of one of the long term medical missionaries but had poor luck and a bloody tap which clogged off the sole spinal needle we had. The patient then passed out, and we aborted the procedure entirely. Because there was no CSF collected, the patient then stood in line a final time at the cashier to receive a refund for the lab testing. It’s hard to compare this experience with doing a procedure in our clinic or emergency room back home. General supplies are considered under the global charge and nothing has to be prepaid prior to it being done. I’m not saying one way is superior (as our method of running up a huge ED bill that a patient may later struggle to pay is also not ideal), but it is a bit of a cultural difference.

Another cultural difference we have experienced this week is in regards to end-of-life care. This has been an area of interest of mine since medical school, and I have rotated with palliative care and hospice in the States so it is interesting to see the differences here. Whereas back in the United States there has been an increase in the number of patients who prefer to die at home and families that want their loved ones home with hospice care, the cultural norm here seems to be that families expect that patients will die at the hospital. There is a lot of guilt surrounding the idea of dying at home meaning that the family may not have “tried everything” to help their loved one. Another cultural norm seems to be that (and I’m quoting a Kenyan physician here) “All Kenyans should die with a full stomach.” As patients are approaching the end of their life, they naturally have a lower appetite and may stop eating altogether. This is considered unacceptable and families will tend to push oral feeding and if need be in the hospital request nasogastric tube feeds. It is not an uncommon site on the wards to see our comfort care patients in their last days with NG tube feeds in place. In America, we typically counsel that NGT feeds in end-of-life care are not helpful, actually increasing aspiration risk and possibly causing more harm than benefit, while definitely decreasing comfort. Here, they seem to remain the cultural norm. Overall we’ve had a very interesting week working in OPD.

We also visited the hospital next door called Cure which is predominantly orthopedic and does a lot of procedures to help disabled children. There’s a large play room and very friendly staff. While we were they we sampled their cafeteria. This is the lunch special of the day (lentils, rice, and chapati) which cost about $2 each.