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.