Thursday, October 20, 2011



By Susan Blaustein | 9.17.2010 at 11:49am |

The following is a guest blog, authored by Stephanie Goff, a senior surgical resident from Columbia University who recently spent time working at Kisumu, Kenya’s New Nyanza Provincial General Hospital.

Let me begin by saying that I am no expert on the subject matter below. For the past month, I had the privilege of serving as a visiting senior surgical resident at New Nyanza Provincial General Hospital (NNPGH) in Kisumu, Kenya, through the cooperation of the Department of Surgery, the Millennium Cities Initiative and the administration of NNPGH.

I have focused my observations regarding health care in Kisumu on five distinct categories: the hospital (its physical workings and its place in the Kenyan health network); the operations themselves (zeroing in on the challenges of coping with limited resources); the medicine (by which I mean at look at the health needs of and preferred treatments for a different population than I have been accustomed to working with); cultural challenges (modern medicine in a land of competing and traditional practices); and critical needs. My understanding and interpretation are based on my experience in Kisumu and on conversations with surgeons, anesthetists, public health workers, nurses and patients.

The Hospital
New Nyanza is a large hospital, and not only by Kenyan standards. This tertiary referral center encompasses in-patient care, out-patient clinics, and a local casualty department (emergency room), supported by a laboratory, a radiology department, and other important treatment adjuncts like a plaster service (for casting) and a physiotherapy department.

Physically, the structure was erected as a gift to Kenya from the then USSR, which explains the nickname it has among the locals, who call it “Russia.” The construction is sturdy cement block, but many of the windows are missing or broken, a fact not readily apparent at first glance. Equipment tends to be in disrepair, but functional.
The wards were a shock to me, as I presume they would be to anyone who has only seen medicine in the American context. A single room on the men’s ward (Ward 2) could be occupied by as many as eight patients, with patients doubling up in the three beds and a foam mattress on the floor. On the women’s and pediatric surgical ward (Ward 1), there were sometimes three small children in a bed, with their mothers crowding into extra space or sleeping on the floor or hallway.

Patients’ relatives serve as the primary caretakers, while nursing staff handles medications. During my time at NNPGH, each ward had 60+ patients being cared for by one head nurse, two or three nurses or medical officers, a handful of nursing students and three interns. A night on the ward will cost a patient 200 Ksh (~$2.50), and various tasks such as starting IVs and changing bandages have minor fees (10-25 Ksh). Interestingly, rather than discharging patients quickly and relying on a billing department to get payment, patients are marked for discharge so that an invoice can be generated, and they aren’t allowed to leave until they present a receipt that their bill has been paid.

The people of this area of in western Kenya are served by local health offices, often staffed by clinical officers. Unfortunately, the quality and training of each differs dramatically. Village needs, including public health projects like malaria and TB tracking, family planning counseling, and early identification/treatment of HIV-infected children, are met by sub-district hospitals. Any difficult birth or more troubling medical or surgical need would be transferred to the District Hospital for evaluation by a physician. Then, if necessary, the patients could be referred to consultants at NNPGH. Major subspecialty care (neurosurgery, cardiothoracic surgery, advanced chemotherapy and radiation), for those patients who can afford it, can be found in Nairobi.

Also of interest to me was that patients are required to maintain ownership of their medical history. They keep paper booklets, called health passports, in which doctors and health workers make notes about their cases. They keep their own x-rays and are responsible for obtaining pathology reports. The patients will often pull a ragged envelope containing their x-rays from underneath their pillow. A patient’s relative has come up to me to give me hand-written pathology reports, which then are noted in the patient’s file. This is obviously very different from the medical records system in the United States.

Just a reminder, though: the structure I’ve been discussing is the government-run hospital system. There are also smaller privately-run hospitals that the wealthier of Kenya’s citizens can choose to access. My surgical colleagues here also attend patients at those hospitals and prefer the cleaner efficiency of the private hospitals, not unlike some American surgeons preferring the small suburban hospital over the urban academic center.

The Operations
The main operating theatre is a well-designed section of the hospital, but it not well-utilized. The antechamber for the theatre is separated into three sections by means of small concrete partitions erected at a level that approaches mid-thigh for most of average height. The largest section is the “clean” pre-operative area that adjoins the corridor of theatres; in this room, staff are required to be in theatre apparel. The two smaller areas are accessed by (1) the main door, which is the entry for staff to proceed into the changing rooms and break room, and (2) a locked door leading to the wards, which is the route all patients take when headed to theatre.

Clinical officers transport the patients to this small holding area, where a theatre nurse will speak with the officer about the patient’s history and vital signs, taking responsibility for a transfer of care, take report and the patient will be moved from gurney to gurney over the partition (cleverly designed to be of the exact height necessary for such transfer). The patient will then proceed either directly to the theatre or to the hallway outside the theatre, for review by the anesthetist.

There are six theatres, designed in pairs, each couplet sharing a preparation area for instruments and supplies and a sluice area for deposition of dirty materials post-operatively, though each has its own dedicated scrub sink closely adjoining the main operating area. Of these six, however, only four are currently operational. One is completely bare and without equipment, and another serves as a large-scale storage area for equipment needing repair and boxes from various surgical missions. Three are used for elective cases throughout the day, while the last is kept ready for emergency obstetrical use. The prep and cleaning rooms adjacent to the theatres are filled with empty cabinets. Anything of value is placed into smaller storage rooms capable of being locked.

As with most operating rooms in the United States, the head nurse is in charge of scheduling, and the anesthetists control the timing of the rooms. In some hands, it is a well-organized chaos, in others, a frustrating morass of inefficiency. Patients ready for theatre are listed by the interns the previous evening, and after brief informal discussions in the morning, a plan is laid for the remainder of the day. On some days, that plan is communicated effectively between staff; on others, less so. There were times when the team was ready to start a late case, only to find that the anesthetists had all left for the day. Nurses and anesthetists have the power to question a patient’s readiness for theater, an important check when dealing with young, overworked interns.

The theatre appears to be running with equipment donated by various non-governmental organizations (Doctors Without Borders, Physicians Across Continents, Operation Smile, to name a few). Theatre lights are in disrepair, often with only one of the many faceted bulbs working. Out of necessity and scarcity, medical professionals reuse instruments designed for single use. Hand-held electrocautery devices (referred to in Kisumu as “diathermy”) have been resterilized so often that the instruments are now warped, molten plastic without any useful internal connections, which need to be controlled by means of a foot pedal. There is only one modern diathermy machine currently working; the other is a 1950s German relic that is temperamental at best. Suction is provided by portable pumps, which are moved from theatre to theatre, as needed.

Scrub sinks do not provide hot water, nor are there effective antimicrobial soaps/brushes available for cleaning. Though we perform the same ritual washing, it is with standard soap and cold water. Gowns are fabric and not impervious to fluid and so require the wearing of a plastic or vinyl apron underneath for protection. Gloves come in two sizes, 7-1/2 and 8, which makes delicate maneuvers tricky for those with smaller hands. All involved wear two sets of gloves for protection. From that point on, surgery is surgery is surgery. The same principles of exploration, hemostasis and surgical technique are present. The instruments are named differently here, with an overall result of simplifying what you’re asking for, but often not being sure what you’ll receive. Ask for forceps, you’ll get a clamp. Ask for a clamp, you’ll get a blank stare. “Dissecting forceps” will get you a traditional Debakey or Adson forcep, toothed or untoothed, depending on what is in the set that has been opened, and may also be referred to as tweezers, but that word, at times, will mysteriously get you scissors, depending on how much attention is being paid to what you’re saying. All clamps, regardless of size or angle, are called “artery forceps” (I presume this derives from “hemostat”).

Patients at NNPGH pay cash in advance for elective operations, and are usually required to purchase surgical supplies. For instance, a man undergoing a prostatectomy must pay 5000 Ksh (~$60) for the procedure itself, a fee that encompasses all “in theatre” (peri-operative) care. In addition, he must supply urinary catheters, sutures, antibiotics, pain medicine, and 100L of normal saline as prescribed to him in the consultant clinic. Surgeons and anesthetists receive salaries from the hospital, and no procedural fees are charged to the patient.

There are very few orthopedic supplies, and when donated plates, nails and screws that have been left have been consumed, patients are required to provide their own hardware, the cost of which is often prohibitively expensive. Because of this, there is an overwhelming number of patients in traction on the wards and a backlog of cases of mal-union that need to be addressed.

The overall feel I had while working in Kenya is that I was operating in a time before the technological advances that have changed the art of surgery in the last 40 years. There is no use of mesh, prosthetic, biologic or otherwise, nor is there laparoscopy, cystoscopy or endoscopy of any kind. Non-operative observation, with which we can manage a number of surgical diseases in the U.S., often requires monitoring and cross-sectional imaging that simply isn’t readily available. As a result, they have a fair number of “negative” explorations, a situation sometimes untenable to an American patient, but readily accepted by patients and physicians here. Esophageal cancers are diagnosed by barium swallow in patients with dysphasia, and colon cancers are not discovered until obstruction or near-fatal gastrointestinal bleed. Benign prostatic hypertrophy is treated not with a simple TURP, but with a prostatectomy. Skin grafts are taken not with a dermatome, but with a skin graft knife, and prepared not by a mesher, but with a scalpel on a sterilized wooden block.

Despite these technological limitations, though, I found I had a lot to learn in this environment. Without scans and labs, I had to learn (re-learn) how to rely on my eyes and ears and hands to diagnose the patients in front of me. Because of language barriers, my physical exam was often all I had to rely on to diagnose patients. Never have I relied so much on the appearance of conjunctiva (anemia or jaundice?), the turgor of skin (dehydration?), or the swelling of a young child’s legs (hypoalbuminemia secondary to malnutrition). I was impressed again and again by the diagnostic capabilities of the senior surgeons.

An area of surgery that was eerily similar to American practice is the interrogational method of surgical education. The frustrations with and limitations of the interns were reminiscent of my time in July as a senior resident to an incoming class of interns. The training process here is based on the British system. Students with acceptably high grades move from secondary school straight into medical school, where, after four years, they receive a Bachelor of Medicine degree. They then start an internship, and provided they complete it successfully, are fully qualified to be general practitioners. After a minimum three years of practice, they can then apply for a Masters program for specialization, such as surgery or pediatrics. NNPGH supports a number of internships, but is not a Masters level teaching program. The interns with whom I interacted are completing a year similar to a “Transitional Internship” supported by some U.S. residency programs, in which they rotate through several specialties.

Overall, it was a relief to find that surgery, like mathematics, is a universal language. The senior surgeons and I may differ in culture, religion and language, but we could operate smoothly together and share stories about the interesting cases that have passed our way.

The Medicine
The overwhelming differences in the general condition of the patient population are primarily the result of exposure to infectious disease and the underlying public health issues that lead to a life expectancy of less than 50 years. Though there have been great strides taken to prevent vertical transmission (mother to child) of HIV in Kenya, the population is estimated to be 25-35% seropositive. In addition to those, the level of malnutrition classifies a significant portion of the community as immunocompromised. This affects, among other things, expected responses to intraabdominal infections and wound healing. It alters choice of suture and type of closure.

Malaria is endemic, and though the disease itself has its own maladies and mortalities, the aftermath of the disease also plays a role in the care of the surgical patient. One particular problem is splenomegaly. Because of the various parasitic assaults on the body, the spleens of children and young adults are not only enlarged, but form fibrous attachments within the abdomen. In trauma literature, the spleen is the most commonly injured solid organ in blunt abdominal trauma. In this population, because the spleen is now a bigger and more tethered target, it is more seriously and frequently injured. While these fractures can usually be managed non-operatively in the United States, trauma patients at NNPGH frequently undergo exploratory surgery and splenectomy. It requires a dogged surgeon and a tenacious social worker to ensure that the government provides vaccines for these children; otherwise the hospital system would discharge them without follow-up, leaving them vulnerable to specific and fatal kinds of infections.

On the flip side, there is a strong sickle cell trait here, as the deformation of the red blood cell renders the patient nearly immune to the effects of malaria. But despite this survival advantage, these children will often have thrombotic events or sickle crises that can cause subclinical necrosis of long bones. Once the crisis is past, the bone remains at risk, and many of these children develop osteomyelitis, which can cause further bone necrosis in a rapidly escalating feedback system. If not treated quickly and appropriately, these children can be left with deformities and inequalities of limb growth that will hinder them the remainder of their lives. While there are such cases in the U.S., they are rare, and osteomyelitis is a disease of diabetics and elderly vasculopaths.

Treatment of some diseases and injuries are determined by the shortage of affordable equipment (such as the orthopedic cases described earlier), but there was one disease – prostate cancer – where there was a clear and substantive difference in approach, and if the surgeons here are to be believed, with similar outcomes. In the U.S., patients with advanced disease would undergo some form of palliative radiotherapy and hormone management, in the form of an injection or pill. Surgery would not be indicated in many of the cases. In Kenya, the primary form of hormone management is orchiectomy, or surgical excision of the testicles.

From a practical standpoint, tools often taken for granted in the practice of medicine have to be revised. Clinicians don’t have access to a full array of pre-mixed IV solutions. IVs are not kept running continuously; total fluids for the day must be calculated and are then divided into boluses to be given throughout the day. It takes creative combinations to give what is considered maintenance fluid. Antibiotics and pain medicines also have different names and dosage schedules. There is no wall suction for nasogastric tubes, and drains are left to gravity.

Perhaps one of the biggest differences between the Americans and the Kenyans is the marked difference in rates of obesity. It is the exception, rather than the rule, to operate on someone with a significant layer of subcutaneous fat. The anatomy of the abdominal wall is more well-defined, which certainly helps with midline incisions and hernia repairs. This may not be the case at the private hospitals caring for the wealthier citizens, but it has been my experience at NNPGH.

Overall, the similarities are many, the differences, few but significant. After adjusting for malnutrition and other baseline characteristics, the surgical outcomes are not dissimilar. Certainly, the in-hospital length of stay is longer, as required for careful post-operative management.

Cultural Challenges
Malaria presented a couple of interesting scenarios. The first was a misconception about symptom and disease, in that the village would treat a child’s fever and presume that the malaria was cured. And while that was dangerous, it wasn’t nearly as sad as the stories some of the interns told me about children with malaria at some of the district hospitals, where the children would become severely anemic and require blood transfusions. In the event of blood shortages, mothers would have to watch other children die and would eventually abandon their children after realizing their fate. The nurses and students would have to do all they could to comfort these children.

But it was on two fronts that I met with more difficult cultural challenges. I will endeavor to use one clinical scenario to discuss both. The first hurdle is one of the strongest sentiments in Kenyan identity, that of tribal affiliation. With that strong community attachment comes a number of traditional beliefs. It is this very system of inclusiveness that leads villagers to take care of the elderly, widowed and orphaned in their tribe. It is because of that sense of responsibility that people can take relatives with medical emergencies to the private homes of local physicians and be welcomed and given assistance at any time of day or night. However, that same sense of duty can lead the women to ignore their own health.

A woman in her early forties notices a small lump in her breast. It isn’t painful, just present, and so she ignores it. A few months go by and the mass has gotten slightly larger. She, herself, continues to ignore it, but her grown daughter, an operating room nurse, mentions it to one of the consultant surgeons. He urges her to bring her mother to clinic, which she is unable to do for about a year. At this point, the mass has encompassed a large portion of her breast, changed the skin and pulled in the nipple. The surgeon recommends mastectomy and the blind use of tamoxifen. Because there is such a strong superstition about the female breast and femininity, and because she would not be able to manage her household, she refuses the procedure. A month later, she returns asking for the surgeon’s help, because the cancer has now broken through the skin and become a malodorous wound.

On the surface, you might be surprised to find that I have no major objections to the course of this woman’s care. She was duly informed of the risks and benefits of action and inaction and autonomously chose, in accordance with her own beliefs, not to undergo the recommended treatment. Would I have chosen differently for her? Likely, but I have no right to dictate her care, and, in fact, would likely have been disappointed in the surgeon had he forced a consent from her.

What if, however, there was another layer to her story? Perhaps she was concerned when she first noticed the mass, but her husband told her to stop being silly and cook dinner. As it got larger, she again mentioned it, in the presence of her daughter, a fact which infuriated her husband to the point that he slapped her after her daughter had left their home. When she finally defied him and went to a surgeon, she returned, knowing that she might already be too late to survive the cancer, but begging him to allow the surgery and the slim chance to save her life. He refused her the money and again beat her. Despondent, she left the subject alone, until he started yelling at her about being smelly and finally consented to let her go to the surgeon.

Such stories are not uncommon, and distress me more than any others. As a doctor and as a woman, I fervently hope that Kenya’s rebirth brings with it a re-education about the rights of women and gender equality. I pray equally that young women in the United States realize the relative safety with which they obtain an education.

Cultural traditions that engender a sense of community and responsibility can enhance the health and safety of a tribe. Even if a belief in tribal superstitions leads to what may be seen as unwise medical decisions, as long as it is determined with complete autonomy, it is not a thing to be feared. It needs perhaps to be better understood, so that physicians can incorporate those arguments when presenting risks and benefits to patients. Most disturbing is the subjugation of women’s rights. It is that cultural challenge that an interloper from America can’t begin to affect; that type of change must come from Kenyans.

Critical Needs
There are so many pressing needs in Kisumu, including major public health projects like consistent, clean running water and food security. On a more immediate scale, the treatment and resolution of outstanding orthopedic injuries could do much to reduce the overcrowding on the wards and free up surgical time for elective cases. It becomes difficult to service the needs of the out-patient clinics because of the surgical burden of the wards. I estimate that a team of well-supplied orthopedic surgeons could optimistically treat and discharge close to a third of the men’s ward.

There is a dire need for even the simplest of surgical supplies. The caps and masks that we dispose of so frequently in the course of a day in the United States are hoarded at NNPGH, and likely throughout many of the hospitals in Kenya. Each staff has a single mask and a single cap that they reuse until they fall apart. Only a certain amount of gauze can be opened for each case, and rather than open more, it will be rinsed in sterile hot water and reused.

Most operating rooms have racks and rooms full of suture – NNPGH has one small shelf of an antiquated glass cabinet. At the end of a long day, it is possible to run out of gowns, and surgical cases will have to be delayed while more are sterilized. Instruments are needed, as are the means to repair and refurbish them. Training is needed, regarding certain practices, such as reserving certain scissors for the fine work of dissecting and using other to cut suture, gauze, etc. It’s a moot point now, because of the shortage of scissors.

I hesitate to say that the hospital could benefit from a cystoscopy suite, if only because the equipment would have to be easily maintained, and the senior surgeons would have to be taught how to perform the procedures. I fully believe that the many patients with benign prostatic hypertrophy would benefit, as a transurethral resection of the prostate is a distinctly less morbid procedure than an open prostatectomy, but I am unsure of the commitment of the repair staff and the willingness of the surgeons to be trained.

There are a horrific number of bad childhood burns present on the ward. In the U.S., these children would be at a major burn center under the care of teams of plastic surgeons, critical care specialists, occupational and physical therapists. At NNPGH, they are all housed in one room, with a small space heater attempting to keep the room warm. Mothers are changing dressings on complicated burns, without any of the topical treatments that are standard. Splints are utilized to attempt to prevent contractures, but the children generally spend their days three to a bed, not allowed to leave the “containment” of the burn room. Biologic dressings would help, but not without a surgeon familiar with their use.

Despite the surgical needs I have outlined, so many of them are material in nature. My experiences practicing medicine at NNPGH showed me that there is no lack of talent or knowledge – both are in abundance in the surgeons and the rest of the theatre team. Yet sometimes it seems that the culture itself can distract from a heightened sense of urgency, with little palpable incentive to be expeditious in the theatre. Tea time can and will delay cases from starting, for instance. Yet it is within that framework that we, as members of the medical community, from Kenya and elsewhere, need to do everything we can to assist the many patients in serious need.