Mar 07 2011
by Rebecca Cook
Vanderbilt School of Medicine
These last two weeks at Kijabe I've been working on the pediatric service. I've worked on a fabulous team in pediatrics. My main "partner in crime" is a Kenyan clinical officer who loves kids and has a tremendous fund of knowledge and experience. Between the two of us, we see all the patients every morning in preparation for team rounds, write their daily notes and orders, and see outpatient pediatric consultations and admit patients in the afternoon. Everyday we go on rounds with a short-term family practice volunteer doctor from the US with years of experience, and a brilliant Kenyan pediatrician who trained at the top national hospital in Kenya.
Although I didn't spend much time in the nursery, I also interact with the nursery team: an amazing American pediatrician who has spent the last 15 years working in rural Uganda and a pediatric resident from India with an incredible bedside manner. We round with a nutritionist or a nutrition intern who not only provide great plans in how to get our babies gaining weight, but also spend a lot of time with families, often informally serving as ad hoc social workers/counselors. One of the best aspects about working at Kijabe has been the diversity and richness of the people I get to work with and learn from everyday.
I've had an amazing range of patients from the "bread-and-butter" babies with bronchiolitis and viral gastroenteritis that are fairly easy to admit and care for, to some really sick little babies with multiple serious medical problems and some surgical conditions I may not see twice in my lifetime. These are the ones that you really get to know and worry about. One in particular is Baby E. He's a 7 month old baby who came to the hospital about a week before I started on pediatrics in a coma, severely dehydrated and really sick. My first day, he had just transferred back to our pediatric ward from the ICU and his condition was still tenuous. Baby E is Massai, one of the most traditional people groups in Kenya; his family lives in fairly remote part of Kenya and eeks out a living through raising cows. I cannot even begin to imagine what it is like for his mother to be in the hospital, a day's travel away from her 8 other children for 3 weeks, she definitely had her moments of discouragement, but at the same time she displayed incredible graciousness and generosity to me as her "baby's doctor."
One morning when I came to examine Baby E she said, "I want to give you a Massai blessing," reached out her hand and gently slid a vibrant beaded Massai bracelet onto mine. Baby E was still in the hospital when I left and to be honest, I don't know his long-term prognosis, he has devastating neurologic sequelae. We were very honest with his family about the extent of the damage and that we did not know how much he would recover in the long-term. I internally struggled in caring for baby E with the tension between providing the standard of care for this individual patient and taking into account the tremendous financial and social burden on this family, especially when the ultimate outcome was so uncertain. By advocating that baby E stays in the hospital to get the oxygen and nutrition support to give him the best possible chance of recovery, what am I doing to the 8 other children this family has at home? Their mother is not with them to care for them or feed them and they are accumulating a hospital bill that is possibly even more than a year of this family's average income. These are impossible dilemmas and it was easy to become discouraged. At the same time, I had to keep reminding myself that despite the hardship for the family he is my patient and my greatest obligation is to do what is best for him.
My final afternoon at the hospital I had a glimmer of hope for baby E. I saw a three year old girl in the outpatient pediatric clinic who had been severely ill at 5 months of age with tremendous neurologic damage but who was now not only still living, but was thriving; she had some muscle weakness on one side of her body but she was a happy, playful three-year old . I hope and pray that this will be true for baby E.
Despite the numerous challenges in the US health care system and the fact that I have taken care of many patients in America without insurance and with tremendous needs, my time in Kenya has been the time of greatest personal awareness (and anguish) of the limited resources of my individual patients and the impact on their care. I have learned good lessons about being creative and ways to reduce waste; I have also had more personal heartache over my patient's dilemmas that I hope will shape the contributions to individual and population level care I have in the future.