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Working in the hospital, with direct patient care responsibilities, is a new experience, but the frustrations are familiar. I was actually rather impressed with the resources available at the Moi University Teaching and Referral Hospital (MTRH) here in Eldoret. Unlike the clinics, health centers and even the regional hospitals to which I was exposed in Ghana and Tanzania, MTRH has a functioning CT machine, a relatively respectable repertoire of laboratory resources, and even a highly functional HIV/AIDS treatment program sponsored by Indiana University and USAID that provides Anti-RetroVirals (ARVs) and even has an Electronic Medical Record (EMR) system. This doesn’t mean that patients in the medical ward don’t sleep two to a bed, that life-saving non-ARV drugs are available swiftly or consistently, or that more than 1 intern is present to cover up to 200 patients when on overnight or weekend call.
Although there is an undeniable lack of resources relative to, say, Columbia University Medical Center, the familiar frustration is not necessarily due to a lack of resources, but due to systems level issues by which it seems that even the available resources not used to their highest potential. The physicians and medical students are generally extremely knowledgable, but this doesn’t seem to translate in to efficient, high-quality patient care. It’s difficult to describe the issue precisely. An example: as you might expect, the in-hospital mortality rate is quite a bit higher here than in the US (though I can’t provide a number). Saying that medical the staff here is more accustomed to death than their western counterparts is a gross understatement. Unfortunately, it sometimes seems that this familiarity saps the sense of urgency from the treatment of acutely ill patients, patients in whom treatments like oxygen, diuresis, or atropine (which are available) may be potentially life-saving. Does this apparent lack of urgency have something to do with a different approach to resource management, by which physicians here have come to terms with the fact that temporizing treatments may be wasted if more chronic care resources are available? Maybe. Maybe not.
Another odd quirk of the system here is the staffing situation. During my two weeks in the medicine ward, daily rounds on the service are attended by between 20 and 35 people. My team had 8 4th year medical students, 4 6th year medical students (they’re on the British system where they do 6 years after high school, then internship), and a mass of other people who appeared on rounds but didn’t seem to be present on the wards otherwise, such as clinical and nursing officers in training. There were also about 2 foreign students present (myself and a Pharm D. student, for instance). Despite this mass of humanity, which makes it all but impossible to hear what is being said about the patients at the front of the pack, there is generally only 1 or 2 interns and 1 or 2 residents per team (of 25-50 patients). Attendings or consulting physicians are present only on some days of the week. The intern is responsible for all the patients, and the resident is rarely present on the ward after rounds. It would be near-impossible for an efficient intern to effectively carry this patient load even if ancillary services (nursing, pharmacy, laboratory, radiology, etc.) were highly coordinated (they’re not), and even if the intern was not sometimes stuck at the back of the crowd and therefore unable to hear the plan of care. As such, because it is essentially impossible for the largely unsupervised intern (assisted by medical students who come and go from classes) to perform all the patient care tasks required, things just don’t get done. Laboratory tests are not sent. X-Rays are not ordered, or if ordered, not performed or not followed-up. Medications are not administered as ordered. Oxygen for a patient in severe respiratory distress may take 30 minutes to arrive. Patients die, and there seems to be little direct accountability or structured quality improvement monitoring. There is a lack of both positive and negative incentives for appropriate patient care. And everyone seems to be used to it.
So that’s what it’s like working in the hospital.
Want to hear about more fun stuff?
Well. My first weekend here in Eldoret, I was lucky enough to be invited by my team intern to head with her and her friends to the Safari Rally being held in nearby Iten. Picture long-distance, 4wd NASCAR, on tiny rural African roads. And Indian barbeque.
My intern is half Yemeni, half Indian, and raised in Kenya. Since she moved to Eldoret for her internship, she has fallen in with a crowd of Indian kids who grew up in town, and represent the demographically small, but economically important Indian presence in East Africa. Their families tend to own factories and large local businesses and most of them attended university in the UK. While it was a quintessentially Kenyan weekend (inasmuch as I was hanging out with Kenyans), one might not have expected camping out on the edge of the Great Rift Valley to involve a caravan of SUVs of pick-ups, Indian food cooked over a gas stove, trance music, and lots of beer. Following an evening of such incongruous culture, we drove out to the race course--120km of apparently randomly selected back-country road--parked on the roadside, and watched cars fly down the tiny dirt tracks at sufficiently breakneck speeds to entertain even American medical students highly skeptic of racing sports.
I dug it.This weekend I ventured out with a few of the other visiting medical students to Mt. Elgon National Park on the Kenyan/Ugandan border. Perhaps I’ll provide further details in another post, as this one is becoming excessive, but lessons learned include: Don’t trust the trail markers in Mt. Elgon Park. Never get separated from the guy in your group with a map. Always carry a flashlight, no matter when you think you’ll be done hiking for the day. Iodine tablets are good to hike with, but a water filter is better. When all else fails, just turn around and go back the way you came, even if it is 15km back to camp. Don’t startle Giant Forest Hogs in the dark. And finally, stalking giraffe on foot through the forest is awesome.
Karibu Africa Tena!
