So....is Nate actually doing anything?

 

Entrance to Tenwek Mission Hospital. Casualty is the ER.

I (Nate) figure it is time to fill people in on what I've been doing in the last 3 weeks here at Tenwek. Although I've seen many interesting cases so far, I will save those for a future post. Instead, I think it would be good for a basic overview about what is being done at Tenwek, especially in the area of Orthopaedics.

First, a little about Tenwek. Tenwek was started in the 1930s as a mission "hospital" by World Gospel Mission missionaries. It was basically a small clinic and dispensary run by nurses until the arrival of Dr. Ernie Steury and his wife Sue in 1959. Over the years, it has expanded to become a 300 bed teaching and referral center respected throughout Kenya and known as one of the finest mission hospitals in the world. The story of this transformation is very inspirational and is relayed remarkably well in Dr. Steury's biography, Miracle at Tenwek (http://www.amazon.com/Miracle-Tenwek-Life-Ernie-Steury/dp/1572932228). This book is incredibly powerful in telling the story of how one man, with a great deal of help from others and mostly from God, can bring healthcare and hope to forgotten areas of the world.

One of the main reasons I wanted to come to Tenwek was to see how they are training residents. Even in America, there are news stories about upcoming physician shortages and the need to train more doctors. While true, the need is a little greater in Kenya. For example, there are currently something like 110 orthopaedic surgeons in the entire country, serving a population of 44,000,000 plus. There are roughly that many orthopaedic surgeons in Indianapolis, with a metro population of about 2,000,000. From my understanding, there are only 4 ortho residency programs in the entire country (Tenwek, Kijabe, Eldoret, and Nairobi). Tenwek is currently in its 3rd year training ortho residents, and is the first PAACS Hospital with a 5 year ortho training program. PAACS (http://www.paacs.net/) is the Pan African Academy of Christian Surgeons and is a great organization focused on addressing the need to train up surgeons to address the huge need across Africa. Obviously, there is a long way to go but this is a much more sustainable way to provide care as opposed to sending American or other Western physicians over for short trips, only to have them leave with the need just as great.




Middle of the Hospital complex. Surgical and Medical wards to the left, old chapel in the center, Ortho ward and clinic to the right. The cafeteria is in the background right and the new church is just down the hill and to the left.

As far as every day life here, things are busier than I expected. On my first day here, the ortho list was 43 patients. In my 5 years at Wishard/Eskenazi, the level 1 trauma center in Indianapolis, our list has never been over 40, at least while I was on rotation. We start each morning at 6am by meeting with the surgery team in the ICU for a brief devotional and then to discuss the new patients that came in overnight.  It is not unusual to have 3 or 4 open long bone fractures come in over night. For those nonmedical people reading this, that means the femur or tibia was broken and then came through the skin. In the US, those patients usually get to the hospital within an hour, have pretty clean wounds, get antibiotics and get tucked in to be fixed, hopefully that next day. Here, we are lucky to see them the same day as their injury. If we do, they have usually crashed on a motorcycle (the "Boda-Boda" is a very common and unsafe means of transportation) and the wound is contaminated with all sorts of mud, manure, and whatever else they fell into. And usually they have waited several hours to find someone to get a car to bring them to a hospital (EMS doesnt really exist here). The other common scenario is where these patients go to a government facility, get "washed out", occasionally closed but often just placed in a splint, and told to go somewhere like Tenwek where they can fix the broken bones. Needless to say, infection is a huge problem in these patients.




Beautiful countryside looking out from the back of the hospital

After signout, we go round on our patients. This gives me a chance to use some Swahili I have learned during our previous time in Tanzania. Interestingly, the Swahili spoken here is quite a bit different. Even Kenyans would acknowledge that their Swahili is poor (although their English is very good). This means that many of the slang phrases we picked up in Arusha leave people with blank stares on their faces. The best part is when you talk to the old ladies, usually with hip fractures, and they only speak Kipsigi, the local language. Thats usually a short coversation (even for an orthopaedic surgeon) that begins and ends with a smile and head nod.




Pediatrics Ward. Kids and parents sleeping under mosquito nets

After rounds, we gather together as the ortho team to discuss the plans for the day. There are usually 2 or 3 consultants (aka attendings), myself (a 5th year resident), a visiting 4th year resident from Kijabe, two 3rd years, a 2nd year, an 1st year and two interns (intern year is separate from residency here). We review xrays of new patients and post op patients, discuss any problems, and then go round on everyone as a team. Before we take off, we always say a prayer which is a good reminder of who is actually healing the patients we are treating.

By 9 we are ready for the OR. We get 2-3 rooms every day. Depending on how many attendings are around, I may be the most senior person in the room. And our cases are not easy. So far we've had a 3 day old talar neck fracture dislocation (the first one of those I've ever fixed), a girl with 4 fractures in her femur (4 segments of femoral shaft along with a basicervical femoral neck), open segmental tibias, 1 year old distal humerus nonunion with no previous treatment, unstable intertroch fractures more than a month old, in addition to the normal acetabulums, femurs, tibias, and chronic osteomyelitis cases. As I mentioned earlier, I will post some of those later.




The OR team hard at work on a hip fracture

Overall, I have been very impressed by the knowledge and surgical skills of the residents here. They dont get much exposure to things like arthroscopy and total joints (knee and hip replacements), but they are experts in open fractures, osteomyelitis, and treating long bone fractures without fluoroscopy. Thats not to mention that they can all do ex laps, C-setions, appendectomies, and all the normal general surgery cases that I would never touch. We do have 2 fluoro machines, so usually 1 of them is working. But we are usually running multiple rooms so we have to pick and choose which cases get the fluoro machine. Now this is something we take for granted in America, using the xrays during surgery to line everything up perfectly. I recently learned that the nation of Burundi has two such machines...for the entire country! Fortunately we have SIGN nails (https://signfracturecare.org/), a unique intrameddullary nail that can be put in the femur antegrade or retrograde, antegrade in the tibia, or even used as a hindfoot fusion nail. You often need to open the fracture site to reduce it (although not always), but then have a long targeting arm to place the interlock screws to provide rotational stability. There is definitely a fiddle factor involved with these, but even the 1st year residents can put these in.



There is a ton of good work being done here at Tenwek and I am lucky to be a part of it. I will try to post some of our more interesting cases soon...there are plenty to choose from.