One of the greatest blessings of living and working in Kenya is getting to be a teacher of surgery. My work at Kijabe Hospital involves working daily with trainees. Some are senior level orthopaedic surgery trainees, honing their skills before embarking on their new career. Some are clinical officers, like a physician’s assistant, who don’t do major surgeries but will be on the front lines of diagnosing and providing crucial early treatment to the injured. Almost every patient we see, and every surgery we do, involves teaching young Kenyan professionals. In a country and a continent with a heart- breaking shortage of trained medical personnel, it is incredibly exciting to watch young trainees grow into confident, and competent, professionals.
Much of the teaching we do here falls under the auspices of the College of Surgeons of Eastern, Central, and Southern Africa (COSECSA). Through COSECSA, I have the privilege of working with and training young surgeons from Burundi, Ethiopia, Kenya, Malawi, Mozambique, Rwanda, Tanzania, Uganda, Zambia and Zimbabwe. South Sudan and Somalia have also applied for membership in the college. This is a college without walls, a huge group of surgeons from Africa, Europe, the UK, US, and Australia, who come together to teach the next generation of African surgeons. Thought leaders in surgical education from around the globe strive to provide advanced training and assessment. The testing and assessment process is in some ways more thorough than the board examinations I went through in the US.
Amazingly, much of the funding and intellectual firepower behind COSECSA has come from the Royal College of Surgeons in Ireland (RCSI). Visiting faculty from both Ireland and the UK come regularly to conduct courses and administer examinations. In accordance with ideal development practices, the European influence lessens each year while the African surgeons take authority over this African college.
Beginning last year, I’ve been privileged to participate in a course called “Managing Surgical Emergencies” (MSE). This is a week long course, aimed at teaching a core set of surgeries that can save life and limb using low technology and limited resources. The course is intricate, and extremely fast paced. The orthopaedic surgery module was designed by my great friend Dr. Yogesh Nathdwaralawa, an orthopaedic surgeon from Wales. The longest lecture is 12 minutes, followed immediately by hands on application of the surgeries taught. A very large pig is euthanized so junior surgeons can learn how to drain blood from a bleeding brain, save the life of a baby and a mother with a rapid C-section, stop bleeding in an abdomen traumatized by a car wreck, recognize life threatening infections and fractures, and other vital procedures.
The course is set in a remarkable surgical skills laboratory located on the University of Nairobi campus. Professors from England, Wales, Scotland, the US, and Kenya teach the different modules. To date, most of the funding and teachers have been from the UK, but with the class we held last week, this ends, and the African staff take over completely. This is an historic and exciting moment in African surgical training.
One of the most remarkable things about this course is its practicality. The students return to their hospitals and immediately start performing these life and limb saving procedures on a daily basis. I feel if only one surgical course could be taught to medical students and interns in Africa, it should be this one.
In the few days since we finished the last course, I have had two patients who demonstrate the vital nature of the MSE course. The first is tragic, the second encouraging.
Victor is 10 years old, the same age as my son Michael. He has been an orphan since a very young age. About four years ago, he developed swelling and then pus coming from his ankles. One of the things we teach in the MSE course is how to recognize and treat osteomyelitis, a common, dangerous, and crippling bone infection. Osteomyelitis strikes the most vulnerable: the very young and old, the malnourished, those with AIDS. Likely because of malnutrition and sickle cell disease, Victor had osteomyelitis in both feet and ankles. The bones of his foot were destroyed by infection, to the point where his tibia, or leg bone, was protruding through the skin. He is a social outcast, unable to go to school, due to the smelly pus and disturbing appearance of his ankles. Xrays showed complete destruction of the bones of the foot. Despite multiple consultations looking for a better answer, the only way for him to survive, go to school, and one day work and have a family, is to amputate both legs below the knee. With prosthetic legs, paid for by our vulnerable patient fund, he will be able to walk, run, go to school, and rejoin society. We met with him, prayed with him, and performed the surgeries this past Monday. Within several weeks, we’ll begin the process of getting him new prosthetic legs. The silver lining of this awful tale, is that he has discovered his faith while in Kijabe Hospital. He is reading a Bible, and wants to commit his life to following God’s will for his life. This has given him a purpose and hope as he faces life with prosthetic legs. Amazing how God can work through even the most miserable of circumstances.
This could have all been prevented with some simple training in recognition and treatment of osteomyelitis in children.
Our second patient yesterday could be diagnosed from the hallway. A 45 year old man had been hit by a motorcycle on Sunday, suffering a moderately severe wrist fracture. A local hospital had put on a full tight cast, something we teach never to do in the MSE course. Overnight, the swelling had progressed to the point of cutting off the circulation to the arm, a condition called compartment syndrome. The excruciating pain and numbness brought him to our casualty department (ER). The astute clinical officers rapidly removed the offending cast, but the cascade of events had progressed too far. As the arm lost circulation, the pain became intractable, and we could hear the poor man screaming from the hallways by the operating room.
Thankfully, the well trained clinical officers recognized the urgency of the situation, contacted the orthopaedic team, and we rushed to casualty. Cases were cancelled, we pushed the trolley rapidly through the halls to Operating Theatre 1. One of our recent junior trainees from the MSE course was by my side, and I asked him to do the surgery he had just learned. He completed the job beautifully with little guidance, saving the man’s arm. Though he will have some scarring, he can plan on having normal function once he heals. I was so proud of our junior clinical officers and doctors, rapidly recognizing and treating this surgical emergency.
These types of disasters and near disasters are a daily occurrence in most of Africa. So much more work needs to be done, but we can already start to see the benefit of basic surgical training. If we could take the MSE course to every corner of this continent, many many thousands of lives would be saved, and even more people saved from a life of crippling pain or disability. It is a great privilege to be part of this process, and we thank God every day for bringing us here.