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An Elective in Kenya
m
An Elective in Kenya ASHLEY SPIVACK GradDipPhys XICsP Ph>hrhcrapist. King Georye Hwpital. LoiiJon
Key words:
Aga Khan Hospital. 'ward work. hands-on approach.
Summary: The article describes an elective spent as a volunteer at the Aga Khan Hospital. Nairobi. Kenya. Biography: Mr Spivack obtained a Graduate Diploma in Physiotherapy
at Guy's Hospital, London, in 1989. He is now working at King George Hospital, Redbridge.
IN my second year a t Guy's Hospital School of Physiotherapy I had already decided that I would spend my elective period in Africa, preferably East Africa and hopefully in Kenya a country which I had visited the year before and consequently fell in love with. During my first visit in 1988 I visited many hospitals in and around Nairobi so that I would gain a broad spectrum of the opportunities available. It took me over a year of continual letter-writing t o various hospitals and rehabilitation centres in Kenya, Tanzania and Rwanda before I was accepted at the Aga Khan Hospital, Nairobi I jumped at the chance. I was t o leave London on July 1, 1989, the day after my last examination, and return on November 22. The Hospital The Aga Khan Hospital, Nairobi, was built using funds raised by the lsmaili community, together with a contribution from the Kenya government, t o commemorate the 70t h anniversary of the Installation of His Highness Sir Sultan Mohamed Shah as the Imam of Shia lmami lsmailia Sect. This was then the biggest single private contribution t o the medical services of Kenya. Planning of the hospital began in 1952 and while still a student a t Harvard University, His Highness the Aga Khan opened the hospital in September 1958, wi th a covering directive that the hospital must serve much more than the lsmaili community in Kenya, or even East Africa. The building was t o become a living monument t o the ideals of racial partnership. One sf the objectives of the Aga Khan in building the hospital was initially to teach and train nurses and other allied professions with a long-term policy of participating in medical training. The hospital is now a recognised nurses' training school and is recognised by various universities for medical internship and for postgraduate specialist medical training. It also participates in paramedical training in conjunction with the medical training centre in Nairobi. The hospital's original accommodation comprised 112 beds with provision for expansion t o 2 5 0 beds. It can now hold up t o 191 patients. The beds are divided into medical, surgical, obstetrics and gynaecology, and paediatrics, w i t h single-room as well as ward accommodation. There is an outpatient and casualty department and many other auxiliary Physiotherapy, June 1990, vol76, no 6
departments. The hospital has 30 appointed consultants and 26 junior medical staff. Over 100,000 people have now been seen in the out-patient clinics and emergency room.
Arrival Upon arrival at the Aga Khan I was cordially met by the head of physiotherapy, Nelson Nyamu, w ho sat me down and poured me a cup of Kenyan coffee - I needed it! It had taken me over t w o hours motoring in my friend's Land Rover t o drive from Karen - south-west suburb of. Nairobi - t o Westlands - a north-west suburb. This unhappy state of affairs was not due t o Nairobi's traffic congestion (meagre compared t o London) but my inability t o come t o terms w it h Kenya's appalling driving standard, Kenya's road traffic accident fatality rate is astronomically high and makes front page news every week. Most of the accidents involve matatus (privately owned minibuses) which shoot around Nairobi touting for business. The competition between these vehicles is intense, so a constant battle is waged to overtake the matatu in front - this naturally turns the roads into race-tracks. After meeting the eight members of staff in the physiotherapy department I was given the choice of working in the out-patient department or on the wards. I chose the latter as I felt I would gain greater experience and see a greater variety of conditions on in-patient duty.
The Work Out of the eight physiotherapists in the department, seven of them work solely in the extremely busy out-patient department. That leaves a sole physiotherapist, Samuel Muema, in charge of the medical, surgical, intensive care, obstetrics, orthopaedic and paediatric wards; he was grateful for the extra pair of hands.'Our day started at 8.30 am on intensive care and here I saw many conditions that I would not see in the UK, eg malaria, dysentery, and acute pyogenic meningitis, along w i t h more common conditions such as acute respiratory infections, myocardial infarctions and renal failure. The ITU department at the Aga Khan is sufficiently equipped t o deal w i t h any ITU admission, but once the patient had been admitted the nurses' drainage, suction and bagging techniques left a lot t o be desired, and it was invariably left to Muema or myself t o show them the correct
The Aga Khan Hospital, Nairobi
357
animals, notably lion, elephant and buffalo. I had the pleasure of visiting among other places the beautiful island of Zanzibar, with its age-old way of life and pristine palm fringed beaches totally untouched by tourism; and the remote Ndoto mountains of Northern Kenya where we lived with a Samburu tribe for ten days. There were also bad moments such as the time when the Land Rover's foot and hand brake cables snapped, in conjunction with engine failure on a downhill course towards a potentially fatal cliff-face at 30 mph - this proved an interesting exercise in initiative. There were opportunities to observe first-hand the terrible impact that poaching has made on the elephants and rhinoceros populations of Kenya and Tanzania - a cause with which I have become actively involved.
A typical Samburu village family
procedures. Patients were also not turned often enough, which led t o preventable pressure sores. A large part of the day was spent on the male medical, surgical ward treating pre- and post-operative fractures, paraplegics and an in-patient who had been in hospital for t w o years following a head injury, and required suction three times a day. One of my most difficult patients was a Somalian from the Northern Frontier District, a semi-deserl area of Kenya sparsely populated with nomadic tribes, Somalis and rebel bandits notorious for ambushing and shooting at vehicles, forcing them t o travel in convoy. He had a wound from a bullet which had entered his right lung and left via his right lower lobe, apparently due to the malfunction of his pistol. Even after accurate translation he failed t o see the purpose of breathing exercises and would simply pretend to fall asleep at the merest glimpse of a white coat. Physiotherapists and doctors alike were not impressed, even less so when a developing abscess and empyema he had developed, which was being manually drained, literally exploded under high pressure and covered Muema, five doctors, including the consultant, and myself in pus. Sadly, parts of Nairobi are notoriously dangerous at night, including one or two areas such as Uhuru Park where visitors are guaranteed t o be mugged at knife point. Consequentlp I treated a number of patients with knife wounds, includinf a woman who was stabbed alighting from a matatu at nighi and who very nearly died from her injuries. She did, however, make a full recovery. The final hours of the day were spent on the largc paediatric ward. Coinciding with my arrival in Nairobi in Jul) there was a serious meningitis outbreak, leading to a largc proportion of patients with meningitis at various stages oi recovery. I was also able to treat bronchitics, asthmatics anc pre- and post-operative fractures. There were also opportunities for a limited amount of in service training. Doctors, mainly from the African contineni but also from Europe, would lecture once a week on thc problems facing health care in the Third World, and providr a gargantuan lunch to boot. Travels in Africa Of course, an elective is not supposed to be all work. Therc were plenty of opportunities t o view East Africa's natura heritage - its wildlife. For me, the feeling of being in thc African bush with only a thin sheet of canvas between yo1 and miles upon miles of Africa and its prolific wildlife wa: magical. We had some fantastic experiences, some good anc some not so good, and some close encounters with wilc
-
358
Conclusion What should one gain from an elective abroad? I can only speak of my experience and subsequent opinions. Clinically, I have gained a great deal - not so much in the sense of physiotherapeutic techniques learned, but in the communication and hands-on approach to treatment that I feel is so valuable. I will remember how my senior, Samuel Muema, placed a caring hand on each patient's shoulder or held their hand prior to each treatment. A hierarchy in stature does not occur at the Aga Khan - surgeons will talk to cleaners, physiotherapists to consultants, nurses to patients, all on a genuine one-to-one level. This is one aspect of treatment which I feel we are losing in the UK. Personally, I have gained many good friends in Peter Munge, Kamau, David Mwangagi, Alfred Mulee, Suleman Deora, Gordon Omwodo and especially Nelson Nyamu and Samuel Muema. I know they will read this article in Kenya and I would like t o thank them for their help and friendship. They will continue to receive students in the future.
Samuel Muema treating a patient with a fibrosed right knee joint
physiotherapy, June 1990, vol76, no 6
An Elective in Kenya ASHLEY SPIVACK GradDipPhys XICsP Ph>hrhcrapist. King Georye Hwpital. LoiiJon
Key words:
Aga Khan Hospital. 'ward work. hands-on approach.
Summary: The article describes an elective spent as a volunteer at the Aga Khan Hospital. Nairobi. Kenya. Biography: Mr Spivack obtained a Graduate Diploma in Physiotherapy
at Guy's Hospital, London, in 1989. He is now working at King George Hospital, Redbridge.
IN my second year a t Guy's Hospital School of Physiotherapy I had already decided that I would spend my elective period in Africa, preferably East Africa and hopefully in Kenya a country which I had visited the year before and consequently fell in love with. During my first visit in 1988 I visited many hospitals in and around Nairobi so that I would gain a broad spectrum of the opportunities available. It took me over a year of continual letter-writing t o various hospitals and rehabilitation centres in Kenya, Tanzania and Rwanda before I was accepted at the Aga Khan Hospital, Nairobi I jumped at the chance. I was t o leave London on July 1, 1989, the day after my last examination, and return on November 22. The Hospital The Aga Khan Hospital, Nairobi, was built using funds raised by the lsmaili community, together with a contribution from the Kenya government, t o commemorate the 70t h anniversary of the Installation of His Highness Sir Sultan Mohamed Shah as the Imam of Shia lmami lsmailia Sect. This was then the biggest single private contribution t o the medical services of Kenya. Planning of the hospital began in 1952 and while still a student a t Harvard University, His Highness the Aga Khan opened the hospital in September 1958, wi th a covering directive that the hospital must serve much more than the lsmaili community in Kenya, or even East Africa. The building was t o become a living monument t o the ideals of racial partnership. One sf the objectives of the Aga Khan in building the hospital was initially to teach and train nurses and other allied professions with a long-term policy of participating in medical training. The hospital is now a recognised nurses' training school and is recognised by various universities for medical internship and for postgraduate specialist medical training. It also participates in paramedical training in conjunction with the medical training centre in Nairobi. The hospital's original accommodation comprised 112 beds with provision for expansion t o 2 5 0 beds. It can now hold up t o 191 patients. The beds are divided into medical, surgical, obstetrics and gynaecology, and paediatrics, w i t h single-room as well as ward accommodation. There is an outpatient and casualty department and many other auxiliary Physiotherapy, June 1990, vol76, no 6
departments. The hospital has 30 appointed consultants and 26 junior medical staff. Over 100,000 people have now been seen in the out-patient clinics and emergency room.
Arrival Upon arrival at the Aga Khan I was cordially met by the head of physiotherapy, Nelson Nyamu, w ho sat me down and poured me a cup of Kenyan coffee - I needed it! It had taken me over t w o hours motoring in my friend's Land Rover t o drive from Karen - south-west suburb of. Nairobi - t o Westlands - a north-west suburb. This unhappy state of affairs was not due t o Nairobi's traffic congestion (meagre compared t o London) but my inability t o come t o terms w it h Kenya's appalling driving standard, Kenya's road traffic accident fatality rate is astronomically high and makes front page news every week. Most of the accidents involve matatus (privately owned minibuses) which shoot around Nairobi touting for business. The competition between these vehicles is intense, so a constant battle is waged to overtake the matatu in front - this naturally turns the roads into race-tracks. After meeting the eight members of staff in the physiotherapy department I was given the choice of working in the out-patient department or on the wards. I chose the latter as I felt I would gain greater experience and see a greater variety of conditions on in-patient duty.
The Work Out of the eight physiotherapists in the department, seven of them work solely in the extremely busy out-patient department. That leaves a sole physiotherapist, Samuel Muema, in charge of the medical, surgical, intensive care, obstetrics, orthopaedic and paediatric wards; he was grateful for the extra pair of hands.'Our day started at 8.30 am on intensive care and here I saw many conditions that I would not see in the UK, eg malaria, dysentery, and acute pyogenic meningitis, along w i t h more common conditions such as acute respiratory infections, myocardial infarctions and renal failure. The ITU department at the Aga Khan is sufficiently equipped t o deal w i t h any ITU admission, but once the patient had been admitted the nurses' drainage, suction and bagging techniques left a lot t o be desired, and it was invariably left to Muema or myself t o show them the correct
The Aga Khan Hospital, Nairobi
357
animals, notably lion, elephant and buffalo. I had the pleasure of visiting among other places the beautiful island of Zanzibar, with its age-old way of life and pristine palm fringed beaches totally untouched by tourism; and the remote Ndoto mountains of Northern Kenya where we lived with a Samburu tribe for ten days. There were also bad moments such as the time when the Land Rover's foot and hand brake cables snapped, in conjunction with engine failure on a downhill course towards a potentially fatal cliff-face at 30 mph - this proved an interesting exercise in initiative. There were opportunities to observe first-hand the terrible impact that poaching has made on the elephants and rhinoceros populations of Kenya and Tanzania - a cause with which I have become actively involved.
A typical Samburu village family
procedures. Patients were also not turned often enough, which led t o preventable pressure sores. A large part of the day was spent on the male medical, surgical ward treating pre- and post-operative fractures, paraplegics and an in-patient who had been in hospital for t w o years following a head injury, and required suction three times a day. One of my most difficult patients was a Somalian from the Northern Frontier District, a semi-deserl area of Kenya sparsely populated with nomadic tribes, Somalis and rebel bandits notorious for ambushing and shooting at vehicles, forcing them t o travel in convoy. He had a wound from a bullet which had entered his right lung and left via his right lower lobe, apparently due to the malfunction of his pistol. Even after accurate translation he failed t o see the purpose of breathing exercises and would simply pretend to fall asleep at the merest glimpse of a white coat. Physiotherapists and doctors alike were not impressed, even less so when a developing abscess and empyema he had developed, which was being manually drained, literally exploded under high pressure and covered Muema, five doctors, including the consultant, and myself in pus. Sadly, parts of Nairobi are notoriously dangerous at night, including one or two areas such as Uhuru Park where visitors are guaranteed t o be mugged at knife point. Consequentlp I treated a number of patients with knife wounds, includinf a woman who was stabbed alighting from a matatu at nighi and who very nearly died from her injuries. She did, however, make a full recovery. The final hours of the day were spent on the largc paediatric ward. Coinciding with my arrival in Nairobi in Jul) there was a serious meningitis outbreak, leading to a largc proportion of patients with meningitis at various stages oi recovery. I was also able to treat bronchitics, asthmatics anc pre- and post-operative fractures. There were also opportunities for a limited amount of in service training. Doctors, mainly from the African contineni but also from Europe, would lecture once a week on thc problems facing health care in the Third World, and providr a gargantuan lunch to boot. Travels in Africa Of course, an elective is not supposed to be all work. Therc were plenty of opportunities t o view East Africa's natura heritage - its wildlife. For me, the feeling of being in thc African bush with only a thin sheet of canvas between yo1 and miles upon miles of Africa and its prolific wildlife wa: magical. We had some fantastic experiences, some good anc some not so good, and some close encounters with wilc
-
358
Conclusion What should one gain from an elective abroad? I can only speak of my experience and subsequent opinions. Clinically, I have gained a great deal - not so much in the sense of physiotherapeutic techniques learned, but in the communication and hands-on approach to treatment that I feel is so valuable. I will remember how my senior, Samuel Muema, placed a caring hand on each patient's shoulder or held their hand prior to each treatment. A hierarchy in stature does not occur at the Aga Khan - surgeons will talk to cleaners, physiotherapists to consultants, nurses to patients, all on a genuine one-to-one level. This is one aspect of treatment which I feel we are losing in the UK. Personally, I have gained many good friends in Peter Munge, Kamau, David Mwangagi, Alfred Mulee, Suleman Deora, Gordon Omwodo and especially Nelson Nyamu and Samuel Muema. I know they will read this article in Kenya and I would like t o thank them for their help and friendship. They will continue to receive students in the future.
Samuel Muema treating a patient with a fibrosed right knee joint
physiotherapy, June 1990, vol76, no 6