Tales from Tenwek: "Tenwek Medicine 101. The Same, Yet Different. "

Over the past two days I have been amazed and overwhelmed as become immersed in Kenyan medical care, and the particulars of healthcare at Tenwek.

Tenwek itself, although quite rudimentary compared to the standards of developed countries, really is quite sophisticated. It has 300+ beds, several ORs, outpatient clinics, an Endoscopy suite, eye and dental clinic, and community outreach. It now houses residency programs for Kenyan doctors in general surgery, orthopedic surgery, OB-gyn, and family medicine. Tenwek recently adopted an electronic medical record which is quite amazing as many health care organizations in the US still are are on paper.

I am serving on the Pediatric service during my stent here, which includes the general pediatric wards, NICU, as well as pediatric patients needing higher levels of care including the ICU and the "HDU" for High-Dependency Unit (similar to our "Step Down Units"). I serve as a senior resident/attending physician and work with Kenyan interns. Internship here is actually a one year program where trainees spend 3 months in each of the 4 main disciplines (surgery, Peds, Medicine, Ob-Gyn) and after that can practice independently as general practitioners or then go on to residency in particular specialties. I am working with 3 wonderful interns and am so thankful for them! They are incredibly smart and hard-working and I am so amazed at how much they are able to learn and accomplish in one year. They are on 24 hr call every few days with no post-call break, and don't even complain!

I am working with an attending named Dr. Gabriel Opondo who is filling in for the US long-term missionary Pediatrician this month. He just finished his peds residency and is unbelievably smart. His knowledge of general peds, specialty medicine, neonatal, and ICU medicine is astounding and I am learning so much from him. There are no neurologists, infectious disease doctors, or intensivists here, but he confidently manages seizure disorders, HIV, tuberculosis, and malaria, and ventilators. Another attending, Dr. Elijah Terer, is a family medicine physician but with a great deal of pediatric background and also so talented and gracious. He began rounds on my first day praying over a patient in the ICU, which was such a humbling and refreshing way to start the day.

It has been quite overwhelming the past couple of days as I try to familiarize myself with the many patients on the service as well as learn about the different medical protocols, medications, daily schedule in the hospital and of course the many diseases that I am unaccustomed to in the U.S. I worry that by the time I become familiar with everything it will be time to leave!

A difference here I noticed immediately is the lack of privacy for patients as the wards resemble the classic structure of multiple beds in a row without separate rooms. Although hard to imagine patients and families hearing about the medical problems and sensitive diagnoses of the other patients, I think it helps to create and sense of community and emotional support among the families. The family involvement is also something quite striking, with most children having at least one or more family members at their bedside constantly. Family members are a key part of nursing care as well and usually take part in feeding their children throughout the day. Infectious control is also something that is not nearly as stringent here as in the US. Although hand-sanitizer abounds in every room, there are no mandates that providers sanitize between patients and no-one wears contact precaution gowns or masks. Only TB patients are isolated.

One half of the Peds Ward. Many family members at bedside of the patients.

Despite some of the aforementioned differences, at Tenwek they are extremely resourceful and creative, making the most of the often rudimentary equipment and technology they have. For instance, they use steel weights hanging from bedposts to support the limbs of orthopedic patients, and use simple graduated cylinders turned upside down in a water-filled beaker to deliver positive pressure to infants (their version of bubble CPAP).

Our typical day on the wards consists of rounding at 9 am.This is typically preceded by a multidisciplinary morning conference but has will not start until next week due to many transitions in the hospital the first week of the new year. We round on the general pediatric wards/ICU patients in the morning until lunch time at 1pm and then come back to the NICU around 2 pm to round on those patients. The intern and supervising physician on call see patients in the ED (called "Casualty") or patients in the maternal child-health clinic who may need to be admitted. We also go to deliveries and C-sections.

One of the features of the day that I have already grown to love is the daily "Chai Time" at 10 am. All of the hospital employees take a break to drink delicious chai tea and sometimes pastries. It is a great time to stop and relax and enjoy each other's company. I so wish we could adopt something like this in the US! During the lunch hour I have lunch at the guest house or am hosted by one of the long-term missionaries. Lunches are prepared by hired cooks and so far have been delicious!

Encouraging mural at the entrance to the Peds Ward

Chapel at the entrance to the Hospital. I'll attend church here on Sundays.

I have seen a wide range of medical cases so far, some very familiar to what I've seen in the US (e.g., reactive airway disease, pneumonia, meningitis, pyelonephritis (kidney infection)), but there have been many rare cases of diseases I've either never encountered or never seen to such severity. For instance, there is a patient just discharged today after a month of hospitalization for tetanus. He was intubated for 25 days and has made a miraculous recovery. In the past few days he has had his breathing tube removed, eating a regular diet, and walking up and down the halls with physical therapy!

A few other interesting/memorable cases thus far:

Anjellah, a 6 yo girl admitted for seizures due to cerebral malaria (severe malaria affecting the brain). I can recall only one case of malaria in the US and never to this degree of illness.

Victor, a 13 yo boy with a brain hemorrhage and abscess in the ICU whom we are treating for suspected meningo-encephalitis (inflammation of brain/spinal cord). He remains paralyzed on the right side and overall not making major progress. It is frustrating that we cannot figure out the underlying cause and have minimal resources left to pursue.

Susan, a 15 yo girl with severe hepatosplenomegaly (enlarged spleen and liver) and pancytopenia (reduced blood counts) of unknown cause. She needs a transfusion before it is safe to biopsy her spleen and do a bone marrow biopsy, but the blood bank is OUT OF BLOOD and we are now relying on her family for donation. Possible causes include leukemia or leishmaniasis (tropical parasitic infection that I've only read about in text books!)

Perhaps the most memorable and heart-renching case so far is a 5 yr old little boy named Ezra who is extremely emaciated (weighing 26 lbs) and malnourished from the combined effects of HIV and tuberculosis. He was also treated for possible malaria as well. His mother was HIV positive and now deceased, as well as three of his siblings. He and is one living sibling are being cared for by his grandparents. Although he is stable now, it is very likely that he will survive another 6 months due to his extreme malnourishment and constant risk of superinfection. I spoke with his grandmother yesterday via his nurse as an interpreter and told her I was praying for healing and most of all God's peace and comfort. She does go to church regularly and I believe she is a Christian.

What I have learned through Ezra's situation and several others, is the that Kenyan people in general seem to be very emotionally distressed by such trying situations. Maybe they have just seen and experienced so much suffering in their lives, but they also seem to be at peace and hold no grudges against medical providers or especially God. After losing her daughter and several grandchildren to a devastating disease I can't imagine not feeling angry or resentful or victimized. I will continue to pray that this precious child receive miraculous healing but most importantly, that God's glory be revealed through his life.