Even though I grew up in Kenya and made the drive often, there has always been something about the Great Rift Valley that inspires a sense of awe each time I see it. Perhaps, it is the sheer expanse of this structure that never ceases to inspire. Not too far beyond this impressive natural landscape, down a steep hill and a winding road whose potholes must be dodged with the lightning quick reflexes of a professional gamer lies AIC Kijabe Hospital. The last time I was in the town of Kijabe was for a camp as a teenager. At that time, a few friends and I imitated the classic 90’s R&B group Boys II Men. I was the bass that would randomly start speaking in the middle of the song saying things like “Girl, you know we belong together” But where were we? Ah, yes . . . Kijabe Hospital. I had just arrived for a month long rotation with the Pediatric Neurosurgery Department and could not wait . . .
I walked into the ward and was immediately struck by the fact that all the mothers and their children were in the same large room in contrast to the largely private rooms I had encountered in Pediatric Neurosurgery rotations in the States. My first thought was how difficult it must be to not have that privacy, but the longer I stayed in Kijabe I began to question that position. I think a moment that captured that reevaluation was when I walked into the ward one day and heard a mother singing to her child in full hearing of the room. What effect did that have on the other mothers? How much easier was it for these mothers to talk and support each other–without walls? Privacy makes a difference, of course, and a private room certainly brings certain conveniences but what do we sacrifice in community to obtain these conveniences? When does privacy become isolation?
Kijabe’s Pediatric Neurosurgery ward primarily consists of children with one or both of two common conditions here: hydrocephalus or spina bifida. Both of these conditions can have devastating neurological consequences if not appropriately treated so the work being done by the neurosurgeons in Kijabe is important and life altering. I had the privilege of scrubbing in on multiple surgeries including shunt placement, ETV (Endoscopic Third Ventriculostomy), Chiari decompression and myelomeningocele repairs. I was impressed by the technological capabilities of the operating rooms in Kijabe. Unfortunately, a fair number of patients present late, largely for financial reasons, when damage has already been done, highlighting the need for certain systemic changes.
In the process, I got to join an outstanding team. Our attending was Dr. Humphrey Okechi who has worked closely with Dr. Leland Albright of the University of Wisconsin, the Neurosurgeon who established the program in Kijabe. Also part of the team were an Ethiopian Fellow, Addis, (and by “Fellow” I am referring to his medical title, not a variation on “dude”!), a visiting senior resident from USC, Eisha, and a Kenyan resident, Peter, from the University of Nairobi. A wonderful senior nurse, chaplain, social worker and other dedicated workers, also supported us.
It is hard to capture the atmospherics of how welcoming it was in Kijabe but let me offer one example. Consider one simple gesture, the handshake. In America, you typically only shake someone’s hand the first time you meet him or her. But in working with this Kenya team, there would be handshakes all around every morning among the team. This simple point of contact provided acknowledgement and a sense of camaraderie that set the tone for the day.
Aside from the OR, my other responsibility was to conduct research on the cost effectiveness of Neurosurgical care in Kijabe. This led to many insightful conversations with mothers of affected children. Aside from expected costs, there were some challenging cultural scenarios they raised, such as being disowned in some cases by husbands whose relatives felt the distorted features of hydrocephalus were an indictment of the mother. It was difficult to hear of the financial struggles faced by many mothers in obtaining neurosurgical care for their children and how far many had to travel to Kijabe, one of only two places in the country to get dedicated pediatric neurosurgical care. But this information also emboldened me further to produce this research as part of an effort to ultimately enhance local capabilities in Neurosurgery.
The interesting and ultimately poignant contradiction in Kijabe was the juxtaposition between taxing neurosurgical cases and a certain lightness in how the staff faced their days. Of course, this lightness did not mean trivializing the high stakes of the patients’ conditions, but rather a refreshing ability to not carry this angst around. One moment, we were in the operating room performing a delicate decompression surgery and two hours later we’re on the soccer field (“football pitch” for any Kenyan readers!). We would play with talented local players and hospital staff many of whom spoke Kikuyu, so my Swahili did not help me with on the field strategizing. After managing to not be entirely useless on the field the first day, I did manage to translate one thing they said . . . “Pass the ball to Obama!”
Several seeds were sown on this trip. The first is the even stronger urge I have to contribute in Pediatric Neurosurgical care in Kijabe and beyond. The second is the need to disseminate the research that will help contribute to this effort. These two seeds will take time to grow. But the third seed can sprout today. It emerges from the ease with which I saw so many people in Kijabe able to experience the present moment despite challenges. And by that, I do not mean to suggest the patronizing sentiment that “those people just seemed so happy!” Many of the parents I spoke to did show signs of strain on their faces as they talked about their struggles taking care of sick children. But it was only in that moment, and their struggles were only part of their stories. Of course, faith was a key component as well; AIC Kijabe is a mission hospital. It all adds up to way of living that challenged me to bring some Kijabe back to the US. Giving people in your team handshakes everyday may seem a little weird here, but the idea behind it is surely worthwhile, the simple power of acknowledgement.
In a little less than two months, I will board a plane and take a trip to the country of my birth, Kenya. I will then drink a cup of home-grown coffee, perhaps two. I have the privilege of taking a fourth year elective in Pediatric Neurosurgery at Kijabe Hospital, about an hour northwest of Nairobi. This trip is 2 years in the making as I originally reached out in 2012 to Dr. Leland Albright, a Pediatric Neurosurgeon at Kijabe Hospital, who has been doing extraordinary work in Kenya addressing the pressing need for pediatric neurosurgical care. My invitation letter says that I will “receive instruction in the neurosurgical examination of infants and children, common disorders affecting pediatric neurosurgical patients, surgical assisting techniques and learn how socio-economic factors affect medical care in a developing country.” Simply put, I am THRILLED about this trip. I will get to work with kids with neurosurgical needs in my home country #fullcircle #can’twaittogetstarted #stillblessed [sorry, I discovered that there is an unspoken rule in social media, of which I will now speak, that your third hashtag, no matter the content of your first two hashtags, must always read #stillblessed].
But back to the trip. Fourth year offers more opportunity than earlier years to reflect. That’s partly a schedule thing, partly an I’m- -almost- done thing, but refreshingly provides moments when the minutiae and logistics can be put aside for a second and the big picture assessed. And that is what this trip to Kenya represents, getting beyond narrow egocentric career goals and really discovering the broader nature of my medical vision. What needs will I see and what role will I ultimately play in the light of those needs? How will the rest of my medical path shape up in response to the answers to those questions?
I have a strong suspicion that this trip will be transformative, and I will attempt to bring the experience to life right here, live, on the Dose of Reality. Stay tuned! #moretocome #Kenya #stillblessed.
The last 3 months have been a flurry of 4am awakenings, drilling holes in skulls, taking care of Neurosurgical ICU patients and tasting what life as a Neurosurgery resident will look like. I spent a month each at Michigan, UCLA and Cedars Sinai doing a series of sub-internships. The intensity of the schedule and sleep deprivation often raised the question of who needed the physical exam more, me or the patient!? In all the haze of activity, it was sometimes tricky to extract the take home lessons or principles, but from these three months, I feel that answers have emerged to two questions I have wondered about:
How will I handle patients with devastating neurosurgical injuries such as severe spinal cord injury?
I had two patients in this exact situation. Here is what I observed; My strongest relationships were with these two patients. Why would that be? I realized that if any patient needed a sense of hope, of fighting to move forward, it was these guys. Each morning, there was a critical moment. I would ask the patients to move a limb that they had been unable to move. One patient made gradual improvement. The other made none. In the few seconds following failure to even wiggle a toe, the doctor’s or trainee’s words are crucial. If I communicate defeat, that’s where things are left and the patient can’t help but feel failure. Instead, I would praise any improvement and where there was none, I would applaud the effort. I would not walk out of the room without communicating that we would try this again and I was in their corner. It is an irony in life that the very thing we believe will be the most difficult, awkward and emotionally draining can then turn out to be the most rewarding, authentic and affirming experience. This is what my spinal cord injury patients taught me.
How do you get technically better while under the direct gaze of supervisors?
I have written before about the common expectation in theatre and surgery in regard to performance. There is a shared vulnerability. When I try something technical in the Operating Room and the resident or attending is watching me, my technique and my ability are on full display. There is no hiding my work or embellishing it. No Photoshop here, all is live. An instant judgment is then made, probably within thirty seconds. Thirty seconds is what most directors give actors in an audition before making a casting decision. That almost seems unfair; a surgeon and an actor are so much more than one moment. Indeed, this snapshot which I call a “performance biopsy” could, like an actual biopsy, be wildly unrepresentative, a limited gauge of actual ability. Yet that moment becomes the basis for a snap judgment. There is no easy solution. But in both spheres, this reality provokes a deeper commitment to thorough preparation which is ultimately a good thing. Because when you are ready and the moment asks you to reveal it . . . that’s where something beautiful can happen.
Neurosurgery is a great field. I am even more persuaded of that now. There are a variety of pathologies to work on from cranial to spine to peripheral nerves. Successful operations can restore normal vision, strength, sensation, the ability to walk, or relieve the most debilitating form of pain. As someone who likes toys, I have also appreciated the Stealth navigation equipment used to target tumors and other innovations. It takes 7 years to train a Neurosurgeon, a recognition of the complexity of the brain and nervous system. Some have wondered if three months of intense Neurosurgery sub-internships has done anything to diminish my drive to pursue this specialty. While I have been humbled by the scope of the specialty, I remain excited to train in this field. It is, in fact, brain surgery . . .
And so last week, I pulled the trigger and submitted my residency applications to Neurosurgery. Now, we will see . . .
Trying to drink from a fire hose. Thrown in the deep end. Pick your metaphor to describe the overwhelmed feeling that you have at the beginning of third year. You do wonder if it will all come together. But the year progresses and something happens. Vague clinical instincts become sharpened by knowledge. A sense of responsibility to the patient becomes emboldened by the skills to offer alternatives.
I am now on Internal Medicine, a cerebral rotation that challenges you to bring together all kinds of information to think of multiple alternatives for what your patient may have and then propose evidence based treatment, sometimes with conflicting data and challenging social contexts all while being ready to adjust your entire thought process by an unexpected clinical development or new clinical guidelines. Yes, that was a long sentence, almost as long as internal medicine rounds . . . but to be fair, these have been teaching rounds in the true sense. I have appreciated being held to account for my proposed diagnosis and plan. It is here that I have been able to detect the curve in the long arc from my first rotation. At the beginning, I could sense something more was needed with some aspect of the care of my patient but did not necessarily know where to go from there. Now as we reach toward the end of third year, this has been steadily changing through the year.
One of my recent patients was tired of constantly being hospitalized for the same set of symptoms every month. The acute treatment always worked but back he came after discharge. I did some research and discovered a medication that was associated with better outcomes than the one he was on, including reduced hospitalizations. I shared this literature with my attending doctor and proposed a switch. By the next day, the patient was discharged on the new medication. Gaining knowledge, feeling more confident as you go through third year is all well and good but when this process results in improved care for your patient, that what really matters. It becomes about more than just you.
Change of scene! For the past several weeks, I have been experiencing my OB/GYN rotations from the halls of St. Joseph Mercy Hospital in Ypsilanti. The last few weeks have been a flurry of catching babies, surgeries with Da Vinci robots, and now working with patients in clinics. With every visit, patient and doctor alike hope for one thing, an uneventful encounter with no concerns. And most of my visits have gone that way, but every so often, there is that troublesome finding, that ominous sign on the ultrasound, and the atmosphere changes from calm breeziness to somber tones. With one such encounter, I just happened to be assigned to the sub-specialty office the very next day where a patient who had just received potentially devastating news was going to receive her follow up appointment. The moment I walked into the waiting room, there was a look of recognition on her face, a flash of comfort, even as she agonized on the impending results. It just so happened I was assigned to the office that day, otherwise everyone she saw that day would have been new. I was a medical student, the one with the fewest answers to her questions, but I was a familiar face, and that made all the difference, it seemed, in those few moments before she thankfully received good news. I have heard the phrase “continuity of care” tossed about and it has always made perfect sense in theory. Today, I saw what this meant in practice. Medical care, no matter how excellent, is subverted by fragmentation. Continuity is often hard to achieve, but worth it . . .