February 20, 2011 at 10:20 am by Robert Jarrett MD
t is rare that we get to address a large chunk of the country’s medical professionals. Perhaps at a well-attended national meeting one may present their late-breaking clinical trial findings to 5,000 physicians at once – 3-4% of the practitioners in your specialty in the US. I was fortunate today to meet and speak with over 25% of the pediatric cardiologists of this 20 million-strong beautiful country. That’s correct, over 25%. All at once. In fact, both of them were extraordinarily nice. In the same vein, we met with 12.5% of the country’s cardiothoracic surgeons. He (Dr. Munene) came to have morning coffee with us.

We spent a productive morning with with Dr. Munene, a hardworking cardiothoracic surgeon and Chief of Service at Kenyatta National Hospital. He told us of the staggering lack of resources and of long waiting lists, of recent local successes in valve surgery and of painful inability to address common thoracic aortic ailments, such as acute dissections and large progressive aneurysms. To repeat, for 20,000,000 people in Kenya, there are 8 cardiothoracic surgeons and 9 pediatric cardiologists. While in the US, CT surgeons generally only do heart and great vessel surgery, Dr. Munene operates on hearts (kids and adults, congenital and acquired disease), he functions as a thoracic surgeon (lung cancer and tuberculosis surgery are common), does esophageal cancer surgery, vascular surgery (peripheral bypasses), vascular access and troubleshooting for dialysis patients and much more. Dr. Munene works from 5 am to 10 pm every day. He has 7 children and besides working at Kenyatta and 2-3 other hospitals, has to do private practice from 5-8 in the morning support their education. Today is Sunday; after showing us around Kenyatta Hospital, he drove away to deal with an arteriovenous fistula problem at another facility.Our initial visit to Kenyatta Hospital was eye-opening. While after 50+ (right, Bob?) trips, Bob Jarrett is a remarkable expert at quickly assessing the status and the needs of the hospital, I am clearly a greenhorn. I want no pity, but am only mentioning this because this amount of audio-visual-olfactory input requires some processing. The latter is not yet complete.

A few impressions, jigsaw-like, will hopefully eventually connect.

The ICU is a remarkably-clean, quiet space. 31 beds house patients, who essentially need to be intubated to gain entrance.Unlike in most hospitals in Europe, where ICUs are fairly compartmentalized by age and diagnosis, all matter of patients here are on the same ward. We met a baby with tuberculous meningitis, an adult trauma patient who was a domestic violence victim, a middle-aged (old by Kenyan standard; life expectancy is 47 for men here) patient with aspiration pneumonitis. Tetanus is not uncommon in villagers who were not vaccinated – this disease is all but unseen in the U.S. With a knowing smile, Dr. Munene mentioned that he hates taking arrows out of chests – after all, the design is such that it only goes easily one way. (Note: if your wife is Maasai, best to take the trash as soon as she tells you). In our brief interaction with the ICU staff, I was impressed by the professionalism and quality of the nurses. The 2:1 patient-to-nurse ratio on the ICU is enviable, even by Western standards.The cardiothoracic/cardiology ward is also clean, though equipment is minimal. Telemetry is available, but not widely used outside of the ICU. Food is centrally distributed, but relatives bring more food (visiting hours are a short 1.5 hours per day). Street food vendors on the surrounding streets lie in wait for relatives coming in at 12:30 in the afternoon to visit. There is nothing for patients to do during the long hospitalization; a small television was a recent addition.

We saw the blood bank – a room adjacent to the transfusion hall. Blood banking in East Africa presents unique challenges. Donated blood is tested for Hepatitis A, B and C, as well as for HIV. Malaria parasite testing is considered an exercise in futility – almost everyone has some Plasmodium in some erythrocytes under the microscope at any give time. The solution is simple: whenever you as a patient get a unit of blood, you also get a single dose of an antimalarial. No questions asked, no problem. Quantity is a problem, also – while an average person after valve surgery may need 1 unit of blood transfused (i.e., from none for most to 3-4 for some patients), to reach that average 1 unit per operated patient, each one is asked to donate 6 units of blood over some time before they get their operation – such is the burden of discarded donated blood due to positivity for one of the viral infections I mention above.Finally, we saw the Accident and Emergency unit, which takes walk-ins and ambulances from all over the city. Truthfully, other than the lack of computer equipment, it looked not entirely dissimilar from any ER in the United States. Same triage –> waiting area –> trauma/critical area –> general area structure.Tomorrow, we meet with the CEO of Kenyatta and then travel to other hospitals. On Tuesday, I plan to see ICU patients in the morning with the team, and then spend the rest of the day in cardiac outpatient clinic. I will need to brush up on my Pediatrics quickly…

more later,

Eli Gelfand, MD

31-bed ICU at Kenyatta National Hospital. Entry requirement=intubation.

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