Volunteer Reflection: Abbie Winkelmann – Kenya III, 2024

Abbie Winkelmann a 4th year medical student at George Washington University.

Mission to Heal: Kenya, April 12-27, 2024

 

Part 1: Trip Logistics

Accommodations: Housing was determined by Mission to Heal as they have a longstanding relationship in the communities that we are serving.  When I first arrived in Nairobi, Kenya we stayed in the Ibis Styles hotel which was a lovely hotel, like any hotel in the US.  Due to the nature of the mission being a mobile surgical mission conducted in large trucks we moved around quite frequently.  At times, we slept in the mobile support unit which contained four bunk beds and one camper-style toilet and shower.  This was a secure and convenient option for the first few nights as we were adjusting to being in Ngurunit.  When there were more than four people travelling with us there were also tents that could be set up should people not want to stay in the local accommodations.  The local accommodations in Ngurunit consisted of a resort called the Golbo Guest House, run by Mama Deema, which acts as a way point for travelers in the Great Rift Valley.  It consisted of little, single room huts which had a bathroom with a basic toilet and shower.  They were open air to allow for the breeze to cool the rooms at night with mosquito netting over the beds to protect against malaria.  During the weekend, after we finished our time in Ngurunit, we traveled to the Lake Turkana Wind Farm where we enjoyed some relaxation.  The wind farm had great accommodations, especially after being in the heat for a week with little way to cool down and limited water for bathroom needs.  The rooms were motel style with comfortable beds, air conditioning, warm showers, and fully functional toilets.  There was even a pool onsite that we swam in on Saturday as well as a convenience store, mess hall and laundry service.  We felt very spoiled at the wind farm!  Our next week we spent in Gatab where we slept in a Christian Missionary Guest House with our wonderful host Katharina.  She made us feel welcome at every turn!  Despite Katharina’s hospitality, these accommodations were lacking some important necessities making this week more taxing.  Our shower was not fully functional and while there were two toilets in the house, neither were able to be used during our stay due to various problems.  We did each have our own room, which was a nice change compared to the previous week where we had little, to no privacy.  Our last night was spent about halfway back to Nairobi in a hotel in Maralal.  Our hotel felt secure, but I would say that the road to Maralal as well as the town itself felt the least safe of the trip.

Transportation: As previously mentioned, our transportation was also provided by M2H by nature of the mobile units as well as supporting safari trucks.  Had we not had the 6-wheel drive military-style trucks and the practically indestructible Toyota safari vehicles, the areas we were going to would have been completely inaccessible. We utilized dirt roads occasionally but that being said the terrain was still incredibly rough.  The roads were also \ crisscrossed by rivers and flood plains, making durable vehicles the number one priority for M2H.  We first drove in the safari truck from Nairobi to the Lake Turkana Wind Farm, where the mobile surgical units were waiting and undergoing maintenance.  From there, we headed to Ngurunit for one week where we parked the MSU’s and set up for clinic.  During that time, we again used the safari vehicle to go back and forth from the clinic site to the accommodations site where we ate dinner and some of us slept.  Then we traveled back to the wind farm for a relaxing weekend.  The following week we again took the MSU’s up Mt. Kulal and parked them at the clinic in the mountain town of Gatab.  Transport was far easier here as we were all in one location and no shuttling between sites was necessary.  We left Gatab, took a pitstop at the Wind Farm for lunch and then headed onward to Maralal.  Maralal was not our original plan for the waypoint between Gatab and Nairobi but due to massive flooding throughout the Kenya the road we intended to take to reach Laisamas was completely flooded.  The road to Maralal was dangerous and required us to pick up armed police escorts, especially with the noticeable and distinctive MSUs and I would not describe this route as an ideal situation by any stretch.  At Maralal we finally hit pavement again and parted ways with the MSUs at they headed on to Uganda and we continued south to Nairobi in our safari truck.

Food: The food was the most difficult part of the mission for me.  Our meals were provided by the local accommodations and consisted of rice, cabbage, a collard greens-like vegetable and stewed goat for lunch and dinner.  This was consistent throughout both weeks with little variability.  As someone who does not eat much meat, at home I tend to be pescatarian, it was very difficult for me to eat the same thing every day and to also get full by a meal with so little protein.  Had I truly been vegetarian or vegan it would have been nearly impossible to keep my diet as everything is cooked in one pot and I would have had to completely bring my own food for two weeks which would not have been practical.  Luckily, one of the M2H coordinators warned me of the limited food options and I brought dried backpacking meals to eat some nights as well as protein bars and other calorie dense snacks to eat for lunch.  I had much better luck with breakfast as they typically had pancakes and fruit and M2H provided oatmeal, breakfast bars and instant coffee for all of us.  We did not do any grocery shopping during this trip and only stopped at convenience stores for snacks when we were leaving and returning to Nairobi.  I would also give a special shoutout to the Ibis Styles hotel who had a phenomenal breakfast with lattes and an omelet station, which felt like a true luxury before we embarked on the rest of the mission. 

Travel advice: I allowed Mission to Heal to purchase my plane tickets and handle the logistics of all the transportation.  They purchased them about a week prior to departure on a Delta flight that was operated by KLM.  I can’t recommend KLM enough, they do a great job with food, entertainment, and comfort.  I flew out of Dulles airport on a six-hour flight to Amsterdam with a five-hour layover and an eight-hour flight to Nairobi.  Nairobi’s airport did have quite a few logistical issues regarding passport control, customs, and security both entering the country and departing.  They recommend travelers arrive 4-hours prior to their flight departure due to extremely long wait times and multiple layers of security.  Kenya requires a visa which was very easy to obtain and cost a minimal fee with very basic information to be filled out through a form on the Kenyan government website.

Part 2: Critical Reflection

The first operation we conducted on the mission was a removal of a submandibular mass which was performed under local anesthesia.  This being my first case I was very unsure of what to expect, both with the relative sterility of operating in the field as well as operating with an awake patient.  In addition to this, doing an awake procedure with a patient who did not speak English added a layer of fear and doubt.  We had to rely completely on our local nurses, not only to learn the procedure and assist in performing it, but also to translate what we needed communicated to the patient.  Given that we were performing a procedure under local anesthesia that we would typically perform under sedation or even general in the United States, I was under the impression that we would be using very large quantities of local lidocaine to minimize pain and any movements that might be associated with the pain.  This was not the case and we used even less lidocaine than I have seen used at home for simpler lump removals.  I was initially quite alarmed that more anesthesia wasn’t being administered and that we weren’t communicating with the patient as much as we would at home due to the language barrier.  I voiced this concern to my attending, that I thought the quantity of anesthetic seemed quite small and that I was concerned we were communicating and asking the patient enough about his pain levels.  My attending was not particularly concerned with these factors and offered to have a larger discussion about it following the completion of the surgery.

Following the surgery, I asked my attendings why the above wasn’t more emphasized so that I could better understand their thought process when teaching the locals and treating these patients.  Basically, it boiled down to that this population has an extremely difficult life, toiling away herding goats and camels with little access to medical providers or medicines.  This makes them extremely tough and used to handling discomfort and pain in their daily lives.  In addition to that, they are very trusting of the doctors who are treating them and need less reassurance than a typical patient at home.  My attendings also discussed that this population is very medication naive and thus have great pain control with far less dosing than an average patient in the developed world might need. For many patients, even a drug like Ibuprofen is a novel medication to them.

This experience was different from past experiences in that I was attempting to do the right thing by advocating for my patient, but it was unnecessary and had potentially dangerous consequences.  I learned that it is also culturally important for the patients in these rural areas who live difficult nomadic lives to feel some of the pain during and following a procedure. For them, the pain in an indicator that they need to be more careful when going about their day and a reminder to take care of the surgical area.  It is very difficult for these nomadic patients to maintain bandages and other infection prevention measures so the pain helps make sure that the patients are doing the best they can with hygiene to decrease the risk of infection as much as possible.  It also helps to keep them from ripping off bandages or accidentally popping stitches which would require a return visit to the local health center.

Moving forward, when I am treating patients in new environments, I believe asking a local expert about common practices will help me to adjust my expectations accordingly.  This applies to pain medications and tolerances in addition to things like antibiotics.  In places where antibiotics are used much less frequently there is far less resistance, making a narrower scope antibiotic an appropriate choice at times. I also believe that it will be important for to listen carefully to that local experts’ response and reasoning behind their logic or customs and ask follow-up questions to gain further clarity.  It will also be important at times to defer to local providers, who are working with these populations all the time, when considering dosing or frequency of medications.  That being said, it is always important to remember the evidence-based medicine that we are taught and the principles that ground us as medical providers whether we are in the US or abroad.