Bomet, Kenya

By: Charles Lehmann

For my trip I elected to visit a mission hospital named Tenwek Hospital located about 10 kilometers outside of Bomet, Kenya.  Bomet is a small Kenyan village located about a four hour drive west of the capital Nairobi on the far side of the rift valley.  Tenwek serves as the primary hospital for approximately 600,000 people living in many small villages and farms within a 30 kilometer radius of the hospital.  It also serves as a referral center for a much larger radius.  The majority of the people in this area are a native Kenyan tribe called the Kipsigis.

I chose to travel to Tenwek Hospital because there is a United States trained orthopedic surgeon who works at this hospital as a full time missionary surgeon.  I wanted to experience not only what orthopedics is like in the third world, but also what the life of a missionary surgeon is like.  On Saturday, January, 26^th I arrived at Jomo Kenyatta International Airport in Nairobi, Kenya.  It was already dark, but thankfully, the driver that Samaritan’s purse had arranged to pick me up was waiting for me immediately after I had obtained my luggage.  He drove me to the Mennonite missionary guest house where I was able to obtain a hot shower and get a reasonable night’s sleep before making the trek to Tenwek Hospital.

The next morning a driver met me and we departed for Tenwek Hospital.  It was a fairly smooth trip by third world standards complete with cattle crossing the highway at numerous points, police officers standing on the edge of the road with machine guns, and a few random roadside baboons and zebras.  After arriving at Tenwek I was given a warm welcome and tour of the hospital and grounds by the orthopedic surgeon that I was going to be working with named Dan Galat.  I quickly realized that it was going to be a busy two weeks since the orthopedic service had greater than 40 inpatients on it and ran 2-3 operating rooms every day during the week.  

Similar to the United States we started the day out with inpatient resident rounds at 6am.  However, prior to starting rounds we had a fairly quick devotional led by one of the residents.  Following resident inpatient rounds we met with the orthopedic attending surgeons and reviewed the x-rays of all of the consults that had come in over the weekend and cases that had been done.  This was performed on a small computer monitor.  (Yes, they do have digital x-rays in the third world.)  Then the entire team proceeded to make other set-of rounds on all of the orthopedic patients that were scattered throughout the hospital complex.  It was remarkably similar to rounds at Washington University other than that we stopped to pray for patients three different times throughout rounds.

After rounds we headed to the operating rooms to start our first case.  We had two operating rooms that were filled with cases.  The spinal’s had already been performed when we arrived and the patients were in the process of being positioned for surgery.  The majority of the OR staff were Kenyan natives, but thankfully all of them spoke reasonably good English making communication much easier.   In the room that I was placed, the first case was labeled AMP.  I assumed that we were going to be amputating somebody’s leg, however I was completely wrong.  AMP stood for Austin Moore Prosthesis (non-cemented, non-modular hip prosthesis – this was one of the original arthroplasty options used some 30-years ago in the United States).  Apparently, this is the cheapest hemiarthroplasty that one can buy (costs $80 from India).  Therefore, working with my mentor Dr. Galat I implanted my first ever AMP.  Another interesting part of my 1st case was that while removing the femoral head, I noticed tumor appearing material in the femoral canal suggesting a pathologic process.  I asked if we should send this to pathology to have it evaluated.  However, I was told not to because this patient was sick and elderly.  Apparently, even if we were able diagnose a specific cancer, the patient would not be able to afford chemotherapeutic medications nor would was their oncologic care that would be readily accessible to them.  Obviously, a very different perspective from how we practice in the United States.  

The second case was a type I open fracture of the tibia and fibula.  We fixed it with a special kind of nail called a SIGN nail.  This is a special stainless steel intramedullary nail designed by a guy in the United States specifically for use in third world countries.  The unique feature of this nail is that you can put the nail in without requiring a fluoroscopy machine.  One is able to do this by reducing the fracture through an open incision.  They also have an extra long jig that allows one to place the distal interlock screws along with several other creative tools that help to ensure that the distal screw is being successfully inserted into the nail.  Despite the lack of fluoroscopy the case went surprisingly well and we successfully placed the SIGN nail in about the same amount of time that it would have take to place an intramedullary nail in the United States.   Following this we did another SIGN nail to fix a closed femur fracture.  We finished in the OR at about 6pm.  Therefore, I didn't have time for much other than eating a little dinner, getting cleaned up, and relaxing for a few minutes before hitting the sack.

The next day I operated with Dr. Kiprono, who was a young Kenyan trained orthopedic surgeon in the 1^st year of his practice.  Our 1^st case was a SIGN nail on a nonunion of a prior segmental femur fracture.  It was rather tricky to find the femoral canal on both sides of the fracture, but non-the-less we were able to get a nail successfully placed in a reasonable amount of time.  The second case was one that I had never seen before – a chronic elbow fracture dislocation.  Dr. Kiprono let me take the lead operating and I was able to successfully open reduce the elbow.  It was quite challenging, but also quite rewarding at the same time.  Our final case of the day involved pinning an unstable fracture dislocation of a fourth metatarsal.

While the operating room conditions were comparable in many ways to the United States, the wards at Tenwek Hospital were strikingly different.  The wards at Tenwek are large rooms that contain anywhere from 5-25 patients and are separated based on sex and hospital service.  Patient fees for staying in the hospital are approximately 600 Kenyan shillings or a little over $7 dollars per day, plus the cost of any medications that they receive.  In addition, the hospital here has moved towards a payment system where patients are expected to make payment for their surgery prior to any elective procedure - fixing a fracture is considered elective.  For example, a common orthopedic surgery procedure such as fixing a femur fracture costs $50,000 Kenyan shillings ($570 US dollars), which is equal to the median monthly post tax income in Kenya.  In comparison to US healthcare this is extraordinarily cheap, but it is a significant amount of money for many people in this region of the country.  By charging this fee the hospital is able to stay mostly self sustainable, and is also to pay the salaries of the 600 local Kenyans that it employees.  Charging a fee also seems to make the patients much more invested in their care.  

During my two week stay at Tenwek Hospital I ended up performing over 30 cases.  I learned a lot of what it is like to be a missionary surgeon in the third world.  I also learned that sometimes you have to accept different treatment options as good enough based on the resources available to you.  If you are interested in reading more about my experience I wrote a more extensive blog along with my personal reflections during the trip that is outside the scope of this summary.  It can be found at http://2013kenyatrip.blogspot.com/2013?m=1