First Impressions

4.13.11

Tumutumu Hospital is definitely an interesting place to work.  After spending 3 days in the hospital I have a somewhat better understanding of how this place and the Kenyan health system operates. Tumutumu hospital's inpatient service is divided into 4 teams- internal medicine, general surgery, pediatrics, and OB/GYN. I am currently placed on the internal medicine team. On the team is an intern, a clinical officer, a consultant, and often a foreign medical student.

The intern is a recent graduate of medical school in Kenya and serves for a year here at Tumutumu. She rotates through the 4 sub specialties in 13 weeks blocks. Basically she runs most of the service as an upper-level resident. Over the year, not only will she lead the medicine and pediatric inpatient services, she will be requried to perform deliveries, c-sections, appendectomies, hysterectomies, cholecystectomies, open reductions with internal fixation, ect. For most of the surgeries a consultant  will not be present. After this year, she will chose either to practice medicine as a general practitioner or continue her training as a specialist. Obviously, this is a big contrast to the way we practice in the US and the interns are given a great deal of autonomy at such an early level in her training. And while she has a good knowledge base, the diversity of her education makes it difficult to go in depth in any particular field of interest.

The clinical officer serves in a role comparable to a physicians assistant or nurse practitioner. He has had 3 years of training in medical education and is now fulfilling a year of clinical duties. He is a hard worker and tends to do the brunt of the paperwork and minor procedures. 

The consultant is basically an attending position. They have specialized into an individual field will oversee the intern. Often the attendings are very busy and will cover multiple hospitals in the area. Often times this means he will show up at sometime during rounding and often leave before or shortly after finishing seeing the patients. He is there to help in difficult cases or solve problems that may arise, but generally leaves the majority of responsibility to the intern. Currently our consultant is covering three hospitals and while he is very intelligent and knowledgeable about Kenyan diseases and treatment he does not have much time for formal teaching.

As in the US, there are often medical students that rotate through Tumutumu. Their responsibilities are not quite as intense as the clinical rotations in the states. There is no pre-rounding on patients and no real clinical duties except to be present and participate in discussion if called upon. Currently we have a UK student who is fulfilling her pre-clinical duties after finishing her exams. She is very bright and engaged and often brings up salient points of discussion. She does not have that much clinical experience, but in her defense, she is required to have a minimum of 7 years of post-graduate training before receiving full privileges as a physician.

Rounding starts at 9:00am-ish. Time is sort of relevant here in Kenya. As noted above, there is no pre-rounding and basically the whole team discusses the patient, recent labs, vital signs, and comes up with an appropriate treatment plan. We start on one side of the ward and walk from patient to patient until everyone has been seen. Once finished with the first ward, we take a tea break and then see the second. The second ward tends to be rushed because visiting hours start at 1:30p, so the team tries to see everyone before their families arrive. In general, we see about 30-35 patients per day, so the service stays pretty busy.

I think the team does very well with the resources it has. Thought goes into every patient in terms of evaluating the deferential, treatment of pain, cost of procedure/diagnostic test, and compliance on discharge. It has a well stocked pharmacy and decent lab (we can even get thyroid studies!) However, the hospital does have its limitations. Basically there is very little that can be done for the unstable and crashing patient. Without an ICU, there is no equipment outside of the operating room to intubate a patient. There are no monitors, no pumps, no Bipap. The lab does not have the equipment to measure HCO3 so no way to detect acidosis. I asked if they could run an ABG and the intern laughed.

Despite these setbacks, I think the treatment here is very good. It's definitely been a learning experience in how to make do with what you have. The physician's physical exam skills are expertly honed and I think it shows me what skills I've lost because of the ease of laboratory testing. I hope that I can impart some small amount of knowledge to them as I am very grateful for what they have taught me.