April 08, 2020

Improving Global Health

By Thomas Difato, MD, a 2019 Goldberg-Reeder Resident Travel Grant recipient and a radiology resident at Wake Forest School of Medicine.

Kijabe is a small rural town over an hour away from Nairobi. The surrounding areas are extremely poor, and although Kijabe itself is considered nice, it has only basic amenities and limited medical resources. Half of the hospital consists of transplanted and volunteer staff, while the other half is comprised of native Kenyans. People come into the hospital under extreme circumstances, because although the hospital is subsidized, the patient costs are often still too high to bear. I've seen patients crawl in on their hands and knees because they have chronic fractures that were never fixed. Strokes that began days or even weeks prior are the norm. Tumors that have grown out of control are also commonplace. These are nothing like what I've seen in my five years of residency.

Despite the lack of access to care, the patients that do make it to the hospital are sincerely grateful for any help they can receive. Even when their loved ones pass, they extend gratitude for every healing effort and action taken to make patients more comfortable. Below is a summary of what our team was doing in Kijabe.

After a couple long flights, we spent the night in Nairobi, bought some supplies, and headed out to Kijabe. We were oriented on the first day. We stayed in a very simple apartment that had basic amenities. Our work schedule included normal business hours during the weekdays, but we also stopped by the hospital numerous times at night and during the weekends at the requests of the clinicians and also to more generally review some of the cases performed while we were not present.

Chris Heald, Peter Zhang, Bhavana Budigi, and I interpreted almost all of the hospital’s CT scans and numerous ultrasounds during our time in Kijabe. We were supervised by Wake Forest University’s radiologists. We were consulted by numerous physicians at the hospital, who brought hanging films of outside imaging for us to interpret because they questioned the reports provided from outside hospitals. These consults were for X-rays, CTs and MRIs. We also performed a handful of imaged-guided diagnostic and therapeutic procedures requested by the clinicians. The case difficulty was off the charts. Very few people go to the hospital in this area, and fewer have radiology studies performed. If someone gets a CT in Kijabe, it is going to be grossly positive, and research/review of articles is routinely necessary because the pathology is very different than what we see commonly at Wake Forest University.

During our four weeks in Kijabe, we worked intensively with the RTs to improve the quality of imaging. More importantly, we prioritized educating the staff to create a lasting effect that would improve patient care in Kijabe year-round. This work included troubleshooting CT protocols during the day on a case-by-case basis, but also providing educational PowerPoints explaining the reasoning for our specific protocols. We created extensive spreadsheets detailing protocols that we adjusted for the limited resources available at Kijabe. The lead CT tech is studying all of the resources we provided, and he plans to continue doing a CME series with all of the RTs to ensure that protocols become more standardized going forward.

The hospital assigned multiple family medicine residents to do a formal rotation under our supervision while we were in Kijabe. We taught basic CT, X-ray, and ultrasound skills to these residents and gave them resources to study at home. We formally evaluated these residents, who all performed very well. We also gave more general lectures to the hospital’s house staff and pediatrics department. Lecture topics included chest, spine, pediatrics, and ultrasound.

Before leaving, I gave the residents our contact information so that they could let us know which topics would be helpful for next time. There is a good chance Dr. Heald will return next year to provide some continuity in our experience and teaching in Kijabe. I hope to return for a third time at some point to supervise residents. Clinicians at Kijabe have also kept in contact through WhatsApp and we have continued to offer consult services remotely on some of the more perplexing cases. Overall, the experience has provided us with profound perspective and has given us a greater appreciation for global health and we plan to integrate our experience and knowledge obtained during our time in Kenya into our practices here in the U.S.