The Peremende Movement

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Ketamine is an anaesthetic agent that can be used in emergency situations. Like when someone is trapped beneath a collapsed building by say his leg. It puts you under in a strange way, and doesn’t quite knock out your breathing the way other agents do. Then an amputation can  be done quickly in the absence of an anaesthetist (anitha-tis, if you interned where i did hehe!), who i like to think of as the guy/girl in the mortal world who stands between life and death on your behalf. In most of Kenya, ‘anaesthetists’ are clinical officers who have had additional training.  Finding a ‘doctor anaeshetist’ outside of the major towns is so rare you’re in better luck finding  a mild tempered man from tigania. So the other day, a newly minted post internship doctor (very very far from being an obstetrician) posted to a center in this country asked in a doctors’ forum what to do when a woman makes it to the hospital by ambulance in the wee hours after having laboured at home for a loooong time, on the brink of suffering a ruptured uterus. There is no anaesthetist, and he’s the surgeon. if he doesn’t operate and the uterus ruptures, the mother will bleed to death, baby will surely die. most people said to improvise and use ketamine and ask the nurse to check her breathing and pulse. It is already difficult surgery to start with, she is a poor surgical candidate,  exhausted, dehydrated, the baby distressed, manoeuvres that will expose her to post op infections have already been attempted by the mkunga at home. But if she arrests on the table, does he abandon stitching her and run to rescuscitate?  And if she dies, and the relatives decide to sue, how shall he tell the court that he was masquerading as an anaesthetist? No licence, no training? This generated a heated debate. Many docs said, ‘kwani, we do did this all the time, for years now even’. Sasa utangojea anaesthetist apostiwe kwenu mpaka lini? If you do nothing, they will as sure as death, well, die. sometimes in the hospital, there is one ninja doc who will keep doing this. He becomes a specialist in improvisation. Which means if he goes on leave or gets sick, is transferred elsewhere or quits to go start tomato planting in a greenhouse, or just gets plain tired of playing God, no one else has the guts or skills to do it. No one though could give as confident an answer to the question, ‘and if you’re sued?’ in another center somewhere, someone said they got tired of practicing loliondoesque medicine and refused to simultaneously play obstetrician and anaesthetist. Neonatal mortality skyrocketed hadi someone in the ministry started asking questions. It took a while, and a number of deaths, but someone at afya house was philanthropic enough to use tax payers money to send an anaesthetist. The moral of the story is that you can attempt to be God and slog on till the next hapless doctor comes to take over where you left off, or you can wait for our deaf and dumb government to finally be moved by deaths so that they can train and post staff that they knew beforehand were needed and just didn’t bother to provide. It is frustrating when you have to deal with a deaf and dumb government i tell you.

This story makes my experience at my internship center sound mundane. In the middle of a CS, i momentarily couldn’t make out one organ from the next due to the pool of blood before me. I was confident though, this wasn’t the first, and it’s expected at times. And then, lights go off. There is pandemonium. I scream for light, she will bleed out  on my call. The anaesthetist produces a nokia mulika mwizi and stands behind me as i ligate those bleeders. The day is saved. But i leave theatre shaking. Now who forgot to pay the elec bill? My internship center was actually quite nice, on the foothills of mount Kenya. But we didn’t have a paediatrician during the 3 months i rotated in paeds. So anything more complicated than malaria or pneumonia or diarrhoea, nilisoma vitabu and attempted to look confident. Paediatricians waliisha embu, which was a 45 minutes drive away. North of embu in eastern province, there was none. i.e in the govt hospitals in Chuka, chogoria, nkubu, meru, isiolo, marsabit, moyale, paediatrician alikuwa tu ni rumour. Later in the year, one was posted to meru, so he used to check in at my center once a week to run a major ward round. Once a week was a few hours of that morning btw. But my rotation was over, i didn’t benefit from a consultant as an intern in paeds.

The only way to get anaesthetists and paediatricians huko mashinani is to, well, train them first. Which is what registrars are doing at KNH and MTRH. Many years ago, i hear it was almost guaranteed. If you do your time, gava pays your fees for 4 years and gives you study leave so you can study in peace. In recent years, some have waited 10 years for the elusive scholarship. Sasa ndio watu wakawa wajanja wakaanza kusakanya peanuts ndio wajipeleke shule. By this time anyway, you have been the district paediatrician, anaesthetist, surgeon, obstetrician, counsellor, hospital administrator and guest of honour at various fundraisers, mainly to take kids to school, parents to (your) hospital etc etc. You can do the work, all you need are the papers. These are the self sponsored doctors who our learned prof in the ministry looks askance at. They are certainly very far from being children of privilege. If you look carefully, they are not asking for any favours. They actually expect to pay their fees. They expect to be taught. They expect to work, as medicine is apprenticeship. What they don’t expect is to work for 80 hours a week. (In Belgium for example, registrars are not allowed to work for more than 48 hours a week, because beyond that, they cease being effective and  patients get a raw deal. We are not Belgium for sure. But neither are we Somalia or DRC. No offense meant to our dear neighbours. Plus we have not been at war for the past 50years).
During one night on call, a registrar in obstetrics in KNH can do 6 or 7 sections, and on that night, make the hospital 2 times the amount of money he is asking for as a monthly stipend. There is a syllabus which stipulates exactly how many clinical hours are needed to fulfil the requirements for a degree, and they are certainly way fewer than 80 hours a week.  However, KNH swallowed the entire arm after tasting a finger. So in addition to doing his 80 hours, the rest of the time (which time?) is spent doing locums so he can get money to keep paying off that loan that was taken to pay fees.  The registrar probably has kids in school and Nairobi rent to pay, a wife or husband to be husband or wife to. These are the docs you will definitely meet in private hospitals in the A&E. Zombie like people. And when you complain (the doctor wasn’t even there when i went to visit my patient, the doctor was in a hurry when i talked to her, my patient waited on a stretcher in casualty for 4 hours before he was seen by a doctor), this is the doctor you are referring to. For the extra hours they are working at knh, they get paid nothing. NOTHING. Lets not even talk about the quality of the degree they are getting, compared to what they’d get in say, san fransisco, where our minister for health frequents and invests in, using the money he’d have bought peremende with for this here doctor. Note that a PSs entertainment and domestic allowance, which is now 150,000 bob, is 150,000 bob more than the doctor removing your gangrenous gut at KNH gets paid. In other countries, na hata hapa Kenya at aga khan, registrars don’t pay a dime for fees, and in addition, they get a monthly salary. And those abroad do amazing things like liver transplants and have access to the best faculty and equipment. So that at the end of another 4-6 years of school, this doctor can go back and serve Kenyans (by the way, even Kenyans who go to private hospitals are still Kenyans, no?)

So these Kenyans, does the government not owe them doctors? And electricity when their abdomens are lying open? And quinine when they have malaria? Let’s not even get to incubators and ventilators, dialysis and radiotherapy  equipment. We are trying to be realistic here and these are stratospheric ambitions to have. A district hospital once got a tin of amoxyl to take them through 3 months by our dear national drug supplier. Haaahaha! (wiping tears from my eyes. It’s so tragic). Btw,  hizo radiotherapy equipment our dear prof was alluding to at some fancy launch to tackle the problem of cancer (which was discovered in Kenya after some of our ministers started to suffer from it), who exactly will know how to use them if registrars are such dispensable commodities in this country?  Mschheeew. Si a time comes for people to say enough is enough?  Wacha mimi nijiunge na hii peremende movement. I think Kenyans stand a better chance with it than with those people at afya house.

The day I did surgery dressed like a priest

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I REMEMBER THAT FATEFUL FRIDAY AS IF IT WAS YESTERDAY. I HAD BEEN ON CALL FOR TWO DAYS, AND I LEFT THE HOSPITAL AT 7.50 AM TO DASH HOME TO GRAB A SHOWER BEFORE GOING BACK TO THE DISTRICT HOSPITAL WHERE I WAS WORKING AS AN INTERN. NO SOONER HAD I GOTTEN HOME THAN MY PHONE RANG. IT WAS MATERNITY, AND ANYONE WHO HAS BEEN THERE KNOWS HOW THE STORY GOES…. YOU KNOW, RIFAROOS AND EMERGENCIES AS THE SISTERS LIKE CALLING THEM. I DASHED INTO THE BATHROOM AND SHOWERED AS FAST AS I COULD. THERE WAS NO TIME TO EAT BREAKFAST, FOR THE AMBULANCE WAS WAITING OUTSIDE. I GOT TO THE HOSPITAL, AND THERE WAS AN EMERGENCY FOR REAL. SHE WAS A PRIMIGRAVIDA, WHO HAD BEEN DRAINING LIQUOR FOR MORE THAN 3 DAYS IN A CERTAIN DISPENSARY WHICH DID NOT DEEM IT APPROPRIATE TO REFER A PATIENT WHO WAS CLEARLY HAVING OBSTRUCTED LABOR. SOMEHOW THE FETUS WAS STILL FIGHTING, BUT THE DISTRESS WAS OBVIOUS. A FOUL SMELL WAS EMANATING FROM THE BIRTH CANAL AND THE FETAL HEART RATE WAS MISBEHAVING. FOR ONCE I HEARD THOSE ACCELERATION AND DECELERATIONS THAT THEY DESCRIBE IN OBSTETRIC BOOKS.
I QUICKLY PRESCRIBED A CAESARIAN SECTION, AND NOT LONG AFTERWARDS, THE PATIENT WAS WHEELED TO THEATRE AS EVIDENCED BY THE METICULOUS NURSING CARDEX. I RUSHED TO THE CHANGING ROOM TO PUT ON MY SCRUBS IN READINESS FOR THE OPERATION. MY FELLOW INTERN, DR. DOREEN, HAD JUST ARRIVED. I WELCOMED HER TO THEATRE. THE ANESTHETIST WAS READY AND THE NURSE WAS BUSY SETTING FOR US. DR. DOREEN AND I HAD SCRUBBED, AND WE WERE WAITING FOR GOWNS TO BE PLACED ON THE CART. THEN SOMETHING UNEXPECTED HAPPENED. THE NURSE ANNOUNCED THAT THERE WERE NO GOWNS. I WAS FURIOUS. IT WAS TRUE THAT WE HAD DONE A COUPLE OF CAESARIAN SECTIONS THE PREVIOUS NIGHT, BUT THAT WAS NO EXCUSE AS TO WHY THERE WERE NO GOWNS. THE NURSE EXPLAINED THAT THE AUTOCLAVE MACHINE HAD BROKEN DOWN IN THE WEE HOURS OF THE NIGHT, AND THE MAINTENANCE GUYS COULD NOT FIGURE OUT WHAT WAS WRONG WITH IT. IN SHORT, THE GOWNS WERE STUCK IN THE DAMN MACHINE.
WE STARED AT EACH OTHER AS WE PONDERED OUR NEXT MOVE. IN OUR NAIVETY, WE THOUGHT OF REFERRING UNTIL ONE OF THE NURSES SUGGESTED THAT WE IMPROVISE. BELIEVE IT OR NOT, SHE GOT TWO ABDOMINAL SHEETS FOR US, AND WE PUT THEM ON. THE SIDES WERE CLIPPED WITH ARTERY FORCEPS. ONE NURSE WALKED INTO THEATRE AS WE JUST ABOUT TO START OPERATING AND HER WORDS ECHO IN MY EARS UP TO DATE. SHE JOKED ABOUT IT. “DR. MBURU AND DR. DOREEN, HAVE YOU CHANGED PROFESSIONS? THE PLACE OF PRIESTS IS IN THE ALTAR WHERE THEY CONSECRATE BREAD AND WINE INTO THE BODY AND BLOOD OF JESUS CHRIST, NOT THEATRE, WHERE BLOOD IS THE ORDER OF THE DAY.”
AS THE ANESTHETIST GAVE US THE GO AHEAD TO CUT THROUGH THE SKIN, ANOTHER NURSE JOKED. “MASS IS ABOUT TO BEGIN! IN THE NAME OF THE FATHER, SON AND THE HOLY SPIRIT.” WE LITERALLY WADED THROUGH THE OPERATION, AND OUR ENCOUNTERS IN THERE ARE EVENTS THAT MADE ME VERY SAD. AS WE MADE A SMILE INCISION IN THE LOWER UTERINE SEGMENT OF THE UTERUS OVERT CHORIOAMNIONITIS WAS STARING AT US. A FOUL IRRITATING SMELL THAT IS SIMILAR TO THAT OF PUNGENT CHLORINE HIT OUR NASAL CAVITIES, BUT THEN WE WERE KEENER ON EXTRACTING THE FETUS. IT COULD NOT GET WORSE. AS I HANDED OVER THE KID TO THE RECEIVING NURSE, I SAW HER FACE DROP. I COULD TELL IT WAS A FRESH STILL BIRTH. THEY TRIED RESUSCITATING TO NO AVAIL AS I BATTLED WITH BLEEDERS. STREAKS OF BLOOD WERE DRIPPING TO THE FLOOR AS IF IT WAS A STREAM. I TRIED PACKING, BUT THE BLEEDING WAS STILL TORRENTIAL. I REQUESTED THE ANESTHETIST TO PUMP MORE OXYTOCIN FOR THE UTERUS TO CONTRACT MORE, BUT THAT DID NOT HELP EITHER. I REQUESTED THE SISTER TO CALL THE LAB TO GET BLOOD FOR THE DYING MOTHER BUT AS IT IS IN OUR LABS, THERE WAS NO BLOOD. IT WAS ONLY WHEN I CLAMPED THE UTERINE ARTERIES THAT THE BLEEDING STOPPED. I ASKED FOR PLASMA EXPANDERS, ONLY TO BE SHOCKED THAT A WHOLE DISTRICT HOSPITAL DID NOT KNOW WHAT THOSE WERE. AT THAT MOMENT THE MO CALLED THE CONSULTANT TO BAIL US OUT. OUR WOES WERE FAR FROM OVER. LONG BEFORE WE KNEW IT THE ANESTHETIST MUMBLED SOMETHING THAT I DID NOT QUITE GET. I WATCHED AS HIS INSTINCTS SWUNG INTO ACTION. THE PATIENT WAS STILL LYING SUPINE ON THE TABLE WITH AN OPEN ABDOMEN AS THE CONSULTANT SCRUBBED WHEN THE ANESTHETIST DID SOMETHING UNEXPECTED. HE REVERSED THE GENERAL ANESTHESIA HE HAD ADMINISTERED TO THE PATIENT. WE STARED AT HIM IN SHOCK. I COULD NOT UNDERSTAND WHY HE WOULD DO SUCH A THING GIVEN THAT OUR PATIENT HAD ALMOST GONE INTO SHOCK. THEN HE EXPLAINED. “THE CYLINDER THAT SUPPLIES OXYGEN IS OUT OF GAS, AND THERE IS NO RESERVE. I HAD TO REVERSE SO THAT SHE CAN BREATHE FOR HERSELF.”
AS I PAVED WAY FOR THE CONSULTANT TO PROCEED WITH THE OPERATION, I FELT A WAVE OF SADNESS SWEEP THROUGH ME. MY HEART WAS HOLLOW. I CHOSE TO BECOME A DOCTOR SO THAT I CAN HELP THE SUFFERING, BUT HOW DO I DO THAT IF I DO NOT HAVE EQUIPMENTS AND DRUGS TO DO ACHIEVE MY GOALS? THE CONSULTANT, JUST LIKE US, WAS DRESSED IN AN ABDOMINAL SHEET, WHICH SERVED AS A SUBSTITUTE TO A GOWN.
TO BRING THIS STORY TO A CULMINATION, I WISH TO STATE THAT THE MOTHER EVENTUALLY LEFT THE OPERATING TABLE STABLE, WITHOUT A CHILD AND WITHOUT A UTERUS. PLEASE BEAR IN MIND THAT THE CHILD SHE WAS CARRYING WAS HER FIRST, AND SADLY, HER LAST.

WRITTEN BY DR. ELIAS NDITIKA MBURU

Pay our Doctors

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Government must take more responsibility for how it spends our money, it cannot continue to waste our money on things that are not priorities and then when our Doctors ask for money they arrogantly say ” You think Taxes are for buying peremendes for sulking children… ” we are not children. That is our money. Pay our doctors.

In Memory of Dr. Henry Gatune

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On Friday 6th May 2011, a patient passed away while in transit from Kiambu District hospital to Kenyatta National Hospital to receive dialysis. He worked in Busia DH and had gone to Kiambu to visit his parents. During this break he developed severe malaria and two days later he had developed acute renal failure for which reason he was referred to KNH for dialysis – this he never got. This patient was Dr. Henry Gatune Medical Officer Busia DH who finished internship last year and he died because Kiambu DH does not have dialysis facilities. No, let’s put that more accurately,

He died because the only places in a country of 40million people and 47 counties  that the government has bothered to put dialysis equipment are KNH, MTRH, Coast General and Nakuru DH.

Acute renal failure is often easily reversible, you dialyse a patient for two weeks and they are back to perfect health – this young doctor who has literally saved lives couldn’t get this. Really!? It also begs the question, if this is what happens to the doctor, what happens to the ordinary citizen? This also highlights the points we have been talking about albeit to a deaf uncaring government – 1. that public sector healthcare provision is a horrific tragedy and 2. that doctors can’t even afford the healthcare they provide – not even when their lives depend on it (and the public so much less so). For instance, if he could afford treatment at the Karen Hospital he would have began dialysis in an hour latest. Better yet, perhaps we should have flown him to Amercia on day one! Instead, his government pays him only just enough to seek treatment in Kiambu district hospital  and KNH – both of which it has severely underfunded, underequipped and understaffed with poorly paid staff.

We have to do whatever it takes, pay whatever it costs to ensure that because of Dr. Henry Gatune, this kind of thing will never happen again in our country. Not while we live.

By Dr. Ng’ani ( Read this story and more at http://www.kmpdu.org/ )

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“His death certificate read that he was a victim of acute renal failure, but the true cause of death was a healthcare system that has failed to demonstrate regard for millions of Kenyans who have no other recourse for a fundamental, critical service.” – The EastAfrican

Among Kenyans failed by the system are the very health workers we expect to dedicate their lives to selflessly battling disease, but whom we fail to give the resources to deliver that care, even to themselves, and even at the very point from which there’s no rescue or return” – The EastAfrican

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