Tuesday, October 18, 2011

The daily trek form Kilimani to Mbagathi

My 14th day in Kenya is only an hour away and I have not gotten to post much about my time in Nairobi. I have been ruminating on several potential blogs topics but have not had the time to develop them fully. I will try to catch-up over the week.

What am I doing here? The short answer is that I am working at Mbagathi district hospital in Nairobi. The district hospital happens to be less than half-block from the national referral hospital, Kenyatta. The proximity means that we have relatively good ability to send complicated patients to a higher level of care.

The long answer requires a good amount of background. First the pubic hospital (healthcare system) system in Kenya, which caters to the 80% of the population is organized in tiers. The bottom tiers are more community based, smaller clinics, which ideally should progressively refer up the chain with more complicated patients. The district hospitals are the sixth level of care before patients have laser-guide their hope onto Kenyatta Hospital. The district hospitals also have some special concentrations/specializations, which they own. In the case of Mbagathi, it is the infectious diseases (HIV, tuberculosis and the likes) referral hospital.

Also a quick summary of the medical health workers structure will be helpful. More like Europe than the US, we have medical doctor education with medical schools, with further training to become medical officers. A few people go ahead with specialization to become registrars, then consultants. There is also a parallel system for a lower-level health workers, clinical officers. Clinical officers (CO) are close to the idea of physician assistants in the US, but COs are not always directly supervised or scrutinized by medical doctors. The lower levels of health care facilities may be entirely run by an autonomous CO. COs have 3 years of -post-secondary school- university level education. Then all graduating COs complete a year of internship at a government approved facility where they spend 3 months rotating through internal medicine (adult medicine), surgery, pediatrics and obstetrics. COs are registered after completing the internship based on varying mix of subjective and/or objective criteria set by the different training locations. A minority of COs do further optional training in the different specialties. The actual real-life responsibilities of COs vary widely based on their expertise, comfort level and how under-resourced their job destinations are; for example ‘minor surgeries,’ deliveries, c-sections, treating HIV are routinely in the purview of COs. The parallel and hierarchical system is how the Kenyan healthcare system has chosen (willingly or not) to deal with delivering health services within limited resources; I do not intend to debate the ethics or discuss the pros/cons of the system.

With that background, I will answer the question. I am working on the female general medicine ward, which has 30 beds but on average about 40 patients are admitted. Mbagathi is a training hospital for COs. CO interns are directly responsible for caring for the day-to-day activities of the patients; each intern has 6-10 patients. The CO interns are supervised by a medical officer (MO) intern, who is responsible for both the male and female general medicine wards (60-80 patients). The MO intern reports to a medical officer, who calls the shots on patient care. The final say, however, is an internal medicine specialist, who is also the medical director of the hospital. Daily patient rounds ideally should be done with the MO, MO interns and CO interns. Twice a week, the specialist comes on rounds. If you are a novice to medical jargon, I am sorry but I hope you are following; I suggest a quick Google or Wikipedia search for unclear words. I am the equivalent of the medical officer (knowledge and experience-wise); I basically run rounds or assist in running rounds in the morning. The afternoons are packed with a variety or procedures: placing intravenous lines, doing spinal taps, ultrasounding peoples bellies, placing grastric tubes, removing fluids for places they should not be; and checking off a crazy-list of mundane things. As you may imagine, the patient acuity level is quite high (probably 50% would qualify for ICU care at any US hospital); and resources are palpably limited.

So, on a regular day, I wake up sometime before 7am; exact time varies depending on whether or not I plan on running. I get to the hospital sometime between 8 and 9 am. My walk to work is 30minutes of brisk walking from the Kilimani residential area. Kilimani is on the edge of Kibera (Google Kibera!). The walk takes me past cars stuck in traffic, dirt back roads, urinating men, charcoal sale stands, chicken cages, and small market grocery stands. My most memorable walking companions are the poof of smoke that inevitably bellows in my face as I walk by some truck or large bus, and the sorry mentally ill gentleman who I encounter two blocks from my apartment gate with half-a-head of dreads as he compulsively scratches the other half. I also walk back home, usually at a more leisurely pace and stopping to by avocado, tomatoes, cilantro or eggplant. That is my working day.

Of course, I have a favorite cafĂ©; I will write about “the Mug” later. I will also surely dish on many other things in the coming weeks.

Avocado heaven

Avocado and beet for breakfast

Swanky Nairobi pad

Nairobi pad-2

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