On The COVID-19 Ward in Kenya

In August and September, I worked at Kijabe Hospital, something I hadn’t done since 2006. Most of the time was spent on the respiratory (COVID-19) ward.

The level of care and the change from a decade and a half ago impressed me. Particularly striking was the clinical competence of a group of physician assistants trained in critical care. Kijabe calls them ECCCOs for “emergency and critical care clinical officers.” And now, even though only Kijabe trains them and there are just 30 graduates, the whole country wants them.

I helped start the ICU back in 2005. (Really, we were doing intensive care before then but it took place in more of a dungeon-noir setting: dark, very old machines, and a lot of room for improvement.) Since leaving Kenya, I had not actually worked in a true ICU. Maua Hospital doesn’t have one, nor did Partners in Hope in Malawi, although we offered fairly advanced interventions for the country at the time.

Now I had to ask myself, “Did I actually once do all this work?” It was hard to imagine. Young men on ventilators following terrible head injuries in road traffic accidents. (Working in the Kijabe ICU reminded me, once again, to approach Kenyan roads with fear and trembling.) Patients requiring extra attention following complicated surgeries, like draining tuberculosis from the spinal canal. A young woman with a neck infection following a dental extraction. A pregnant mother with heart failure from a dysfunctional thyroid.

The intern doctors and ECCCOs did a great job managing these complex cases.

Another striking feature of my time on the COVID ward was the sheer amount of oxygen required to save lives. Kijabe is relatively well-resourced in this regard, but even its system strained under the burden. (An outside consultant suggested the hospital required twice its current capacity—and that was before COVID.) Just four or five patients with this virus could use a third of the hospital’s entire supply.

Clearly at times we were not obtaining pure oxygen out of the wall. On busy surgery days, when the operating theaters sucked more of the supply, we could see oxygen saturations decline in the sickest COVID patients. Switching to the pure oxygen in cylinders wasn’t a sustainable option. A large, expensive cannister could be drained dry in less than a day.

We had a few patients receive oxygen via “high-flow nasal cannula” (HFNC). You have probably seen this device in pictures of American hospitalized patients. The tubes in the nose are thick. The flow rate ranges from 25 to 60 liters per minute. Kijabe’s total capacity is 325 LPM. Maua’s is 45 LPM—for the whole hospital, and it’s one of the only facilities in the region north of Mount Kenya with piped oxygen. This HFNC device certainly saved lives and is fairly easy to use—if you have enough oxygen.

COVID patients can require supplemental oxygen for weeks. One patient had been on medical oxygen for a month when I left the service. He had suffered a heart attack as part of his illness. We were reluctant to send him home until his oxygen saturation level normalized. Some families in central Kenya can afford a home oxygen concentrator. Of course, this machine requires continuous electricity. Blackouts are common.

We cared for a patient at Maua whose lungs had been destroyed by rheumatoid arthritis. She basically lived at the hospital because she couldn’t survive without extra oxygen. A local politician bought her a machine for home use. One day the power went out and she died.

The pandemic has increased interest in supplying oxygen in Africa. The situation was dire pre-COVID. Only 20% of health facilities have access to any kind of oxygen. AMH is hoping to install oxygen systems at partners in Kenya and Malawi with the capacity to distribute cylinders to other facilities.

The sheer amount of resources—gowns, aprons, gloves, masks, disinfectant—required to run a COVID ward is staggering for a resource-limited setting. We did have enough personal protective equipment (PPE). We are grateful to those who supported our COVID Response Fund. Kijabe formed a COVID committee which did a great job establishing protocols. The preparation made a difficult situation manageable.

The epidemic in Kenya had improved before cases spiked again over the last couple months, as they have in much of the world. The death rate has been far lower than in the US and Europe. I explore possible reasons in this article and interview. The greatest impacts are probably yet to be fully known. Interruptions of routine care threaten progress against vaccine-preventable diseases, HIV and TB. Access to surgery is another casualty as any patient with respiratory symptoms must be isolated awaiting a negative test result. Like in the US, we desperately need a faster test.

The experience reminded once again why I love living and working in Africa. The sense of mission, camaraderie and purpose. The struggle and service on behalf of those with few other options. The love and gratitude extended by families. After finishing my stint at the hospital—and returning to my “normal” work overseeing projects and balancing budgets—I told Amanda that I prefer fighting a deadly respiratory virus over reviewing emails and spreadsheets.

Yours in Struggle,

Jon Fielder, MD