Written by Deepika Parmar, MD, PGY-2 at Kaiser Permanente Oakland Pediatrics Program while on Global Health…
From the moment I stepped off of the plane, I was greeted with warm smiles and friendly curiosity. “Is this your first time to Kenya? What are you doing here?” These were frequent questions and I often answered timidly, not sure how the locals would respond. All over Africa, there were missionaries and organizations present to “help” the people living there. The signs of poverty were many: dirt roads, mud huts, shoes with holes in them, if shoes at all. Yet, here were people who appeared happy and industrious and I wasn’t really sure what my role was and even more, did they really need my help? “I’m here to do work with the Matibabu clinic and perform surgery,” I would say. This would strike up lots of conversation and usually a story about how the clinic had helped a family member or themselves. I could tell we were in the right place working with the right people.
The first week of my rotation was spent working with the clinical officer at Matibabu clinic in Ukwala. The clinical officer, Dorah, was an amazing woman and knew SOOOOO much. She essentially had the training of an internist after 1 year and was expected to treat anything that walked in the door. This could be as simple as a cough or cold, to a fresh wound or chronic infection. She saw young, old, men, women with all problems and she had it down. Her job was to provide as much care as she could in the rural setting and identify when the patients needed a specialist, which sometimes they did. Then she would send them off to Siaya, Kisumu or Nairobi. Now I will admit, my contribution was not all that great, since she saw a lot of children, malaria and diarrhea, none of which I have much experience with, but I learned a ton about common infectious diseases such as malaria. I also learned I better use my mosquito net and take my prophylaxis. During this week, we also spent time working at a maternal child health clinic. Many women in the rural areas were still birthing their babies at home, but there was a strong push to have more women delivering in the hospital (which the government covered). However, one thing that really stood in the way of this was accurate dating and consistent prenatal care. Women often showed up well into their 2nd or 3rd trimester for their first prenatal visit. Ultrasound facilities were limited, so most women were dated by the LMP (last menstrual period), which could be highly inaccurate. Once women had an EDD (estimated date of delivery), they would often move or stay with family members closer to the medical facilities. But as you can imagine, these due dates could be as much as 3-6 weeks off and there was no telling whether they’d make it to the hospital in time if they weren’t nearby. So part of our contribution was providing ultrasounds for dating. This could help confirm due dates or re-date them to make their future travels a bit easier. Every woman also received prenatal testing at this visit (Blood type, HIV testing, etc).
During this week in the clinic, we also spent a day doing community visits. We went with a community health worker to people’s homes who were infected with HIV. These individuals ranged in severity of their illness from mobile and relatively healthy, to bed bound and unable to leave their home. One individual who really stuck out was a woman named Helen. She was HIV positive and lived in a small mud hut in rural Ukwala. For the past year, she had been completely bed bound because she had developed bilateral lower extremity paralysis. She had 2 small children, but was unable to care for them because she could not get out of bed. She was advised to have an MRI to evaluate whether or not she had a spinal lesion, but she couldn’t afford it, so didn’t have it. She complained that she had been having increasing abdominal distension as well and was unable to tell when she had to urinate but it would sometimes just leak out. As we walked into her hut, the whole place was permeated with the smell of stale urine. Because she couldn’t get up, she spent all day in bed, went to the bathroom in bed, etc. She was advised to use a foley catheter, but it was too uncomfortable, so she decided to just remove it. Her bladder was above her belly button. We struggled with how to help her. We knew that she needed imaging, but the least we could do was offer her a foley catheter. We explained the need, but she didn’t seem too interested. In addition, we weren’t really sure how much it would help. We could empty her bladder, but that may put her at higher risk for a urinary tract infection and sepsis, which could ultimately lead to her demise. We were stuck with wanting to help, but not really knowing how. This is an example of how simple clinical decisions that I make every day (place a foley, order an MRI) can become much more difficult when the conditions are different. It really made me rethink all of those “simple” decisions.
During the next week, we performed surgeries at Siaya District Hospital, a basic, well-functioning, government-run facility in rural Kenya. There were 2 operating rooms, connected by an open doorway. No air conditioning was present, instead the rooms were hot with fans that sometimes worked. The facilities were clean, but the concept of sterility was slightly different. Resources were minimal: bovie pads donated by previous clinicians were reused and taped to each individual. Bovies, which are regularly thrown away in the United States after one use, were re-sterilized and used until they were cracked down the middle. Sutures used were those that were left over from previous groups. Cloth gowns, masks and surgical hats were used. Electricity was present, but frequently went out or there often weren’t enough plugs to power all of the machines we needed to do a surgery. Despite this, we were able to operate on patients and provide safe and adequate care.
The operations we performed were anything from a tubal ligation to removing a 12.5 pound uterus filled with fibroids. Each operation was challenging in one way or another. I learned through this experience exactly what I needed right down to the number of suture and what type, for each operation. Take for example, the hysterectomy we performed using a cesarean section tray and heany clamps. All of the major laparotomy sets were in sterile processing, as they were not used to performing so many operations, so they asked, “Can you use a cesarean section tray?” Now if I had been in the U.S., I never would have done it, but I knew I had no other choice (and of course, the patient was already asleep, because they didn’t figure it out until then). So I looked through the set and it had retractors, Kelly clamps, cochers, pickups and with our supplemental heany clamps, our set was complete. We performed several hysterectomies with the cesarean tray (not by choice) but soon I realized what tools I truly needed. In a similar fashion, I learned a lot about the number of suture needed for each case and how to run all of the electrical equipment used. Before every surgery, I opened exactly what was needed suture wise, no more because you would never want to waste it. I also hooked up every bovie machine and made sure all the pieces were functioning. These were all things I took for granted when operating, but soon learned about their importance.
In addition to all of the logistical knowledge I acquired, I also learned a lot about gynecologic disease in Kenya. Many of the women we operated on had evidence of previous pelvic infections. The layers of adhesions we encountered were impressive leading me to believe many women have longstanding PID (pelvic inflammatory disease) that never receives treatment. And just like women in the U.S. who have a history of PID, these women had trouble conceiving. The unfortunate thing is that for many with tubal disease, IVF was not ever an option. So I can only imagine how these women could be ostracized because they would never be able to conceive. Similarly, the incidence of fibroids was high. We took out 2 uteri that weighed over 2.5 kg as well as one that weighed 5.6kg. These women had been suffering for years with heavy bleeding or abdominal pressure and distension leading some to wonder if they were pregnant. The look on their faces after we were able to remove their uterus was indescribable. It was life-changing for them and no local doctor would ever touch them because the operation was too risky. But luckily, their procedures went smoothly and were without complication.
My experience in Kenya was indescribable and the impact it will have on my future practice of medicine is yet to be determined, but I know it has changed. I met people with such spirit and such gratitude that I knew my work was worth it and that I had made a few people’s lives better. It’s difficult to express all of the emotions that run through one’s mind after an experience like this, but as I continue to process all of the emotions, I will continue to reflect on everything I’ve learned in the hopes of one day returning to Kenya or another part of the world to share in the knowledge I have obtained.