Kijabe Experience – Hakuna Matatu
April 9th, 2020 by Preston Houston
Posted in Uncategorized|
*Read more about the Kenyan experience at my blog DrJourneyman.voyage *
This is a quick summary of the “need-to-know” facts about rotating in Kijabe from a Family Medicine PGY-3.
Hakuna means “there is none”
Matatu means “bus”
February 2020 to early March I was at Kijabe hospital for an INMED elective. It is a small town at ~8000 ft elevation. The hospital is well renowned in Kenya due to the fact that they have many missionaries and more services than the avg hospital (people would bus 4+hrs to have an appointment and wait overnight sometimes. The town has all necessary amenities for survival: a dormitory with showers and a private bed, local shops and stands with vegetables and meat, a convenience store with toiletries, bottled water, and coffee; there is a few barber shops. Taxis are easily found – people will take you in private vehicles for a steep price, the hospital will recommend one for you but it was good to have a Kenyan friend haggle the price or compare between drivers.
There is no publicly accessible gym. No stores in Kijabe sell alcohol and consumption is highly discouraged. Bible study groups are plenty, but church is not requiered. Dorms do not have WiFi (the hospital has wireless internet that is usually functional). There are buses “matatus” but I did not take them as we had a mass casualty of 19 people and frequent accidents reported with these aggressive drivers (though it’s $2.50 to get to Nairobi instead of $40 with a private driver). Kijabe has 1 restaurant and a few food stands which I did not try.
To get most “modern” things you need to go to Nairobi which is 1-2 hours depending on traffic.
Wards are what you would expect in sub-Saharan Africa: multiple beds in 1 room. There is a private ward for high-paying patients and a semi-private for those in between. The ICU has 4 vents and 5 beds. Hospital is staffed by Kenyan and missionary physicians. High emphasis on education with interns having daily lecture and free lunch from 1-2 p.m. Services include ENT, IM, Peds, FM, OB, Palliative, Gen surg, ED, ortho, TB/HIV, and seldom other sub-specialists. If there is a case where you need a consultant – you may try and call Nairobi but sometimes it is difficult to get an answer. Hospital has a CT scanner and US but no MRI.
The following are my 1wk experiences per rotation.
Outpatient department is a hybrid urgent care and primary care. Patients will come in with a list of issues and you have to parse through what is relevant. No appointments. Patients are served in the order they arrive. In one visit I would address MSK complaints, screening tests, and lifestyle counseling because I knew that patients were sacrificing their resources to get help. Sometimes there were semi-urgent workups that would need admitted – patients would come in with pneumonia and hypoxia – I would staff with the attending inpatient and get them in. Spent a lot of time finding cost-effective care. Prices are listed in the EMR for each test. EMR worked slowly and with glitches – but they said they were going to roll out a different one potentially in the future. 4 hour didactics on Wednesday including an office visit in front of colleagues to improve clinical skills and reasoning. Fascinating cases with advanced progression of typical disease. Physical examination is a capital way to save patients cost.
Casualty (ED) – run by the FM docs and an American EM doc with US fellowship. High emphasis on teaching. There are around 10 beds. Lots of orthopedic trauma, lung issues, strokes, liver failure. In this rotation you may have the opportunity to do LP, thora, and paracentesis. General or orthopedics will take most of the chest tubes or fasciotomies of they are needed. Most stat labs are available (lytes, CBC, rapid HIV or gene expert for TB, x-ray, POCUS, ESR and CRP, cultures, thick smears etc). If patients could clear their bill and needed services we could provide, they could be admitted. There was no dialysis, neurosurgery, interventional cardiology (no caths) or chemotherapy – so if patients needed that they were either referred or transferred to a facility which would provide them.
Peds – Had ICU, NICU, and may beds. Rounded on general peds. Wrote notes and put in orders. Lots of infectious disease – parasites, pneumonia, UTI, HEENT infections. Low immunization rate – so plenty of diseases we don’t see often in the USA. Run by volunteer pediatricians. Learned a lot of rare congenital issues, malnutrition and refeeding, AIDs in children, and sepsis.
OB – I spent one day here. Nurses deliver babies but would teach rotating residents if desired and there were rotating obstetricians who were doing most of the operating. FM covers call and does c-sections (including twins) and ectopic removals. Their skills put most FM programs in the USA to shame. Dr. Stella is a wonderful teacher. If rotating here – should spend the whole month in this one department. Very education heavy. They have fetal monitors but they are used not as heavily as in the USA.
ICU – I served as an observer/adviser to the training interns and nurses. Run by volunteer FM and IM docs. No critical care fellowship trained personnel. Many pressors available. Tough to get consistent I/Os at times. 2-3pm lecture on critical care medicine.
Inpatient – Standard cases as seen in USA: HHS, DKA, perioperative medicine, AKI, CVA, COPD, PNA, cellulitis, CHF. Also with classic things seen in this region: pulmonary HTN, peripartum cardiomyopathy, myasthenia gravis, lots of meningitis, liver failure from TB meds, TB meningitis, HIV/AIDS, multiple malignancies, parasites, and odd exposures including sequelae of witch-doctor medicine. I served as consultant with attending backup. Interns did all notes and medications but required variable levels of supervision. If patient needed monitors they went to stepdown which was managed by ICU team. Labs are on an as-needed basis. Sometimes imaging takes a day. All imaging self-read unless the radiology residents were there – otherwise there is a wait. Good working relationship with surgical team.
Call – 1x per week and 1 full weekend of 48h call. I took adult inpatient only. Can be phone only – but with some interns the clinical picture was not clear enough to trust that the patient would be OK until the day team rounded. Average 1-7 calls per night and I had anywhere from 0-3 admissions and consults.
M&M for 1-2 hours each Friday. Usually accompanied by QI initiatives.
Dessert nights with fellow volunteers were on Mondays. Safari discount to world-renowned Masai Mara. 1h away Naivasha resorts are a good getaway with decent restaurants and resorts.
Overall I would recommend the experience. It is light on procedures and surgery but very heavy on teaching and with an interesting case balance. Not many tropical diseases as it is not a tropical climate. Faculty is all very approachable. I will attempt to go back when I can to help relieve the attendings, as they are always on call when a rotator is not taking first-call.