Conversation with PAACS Anesthesiology Resident about medicine, systems, compassion, faith and building for the future.
David: So, first off, just tell me your name and where you're from. And then maybe how you came to Kijabe.
Rebecca: Okay, my name is Rebecca Dufe. I come from Nairobi. How I ended up here in 2020, there was an advertisement for Anaesthesia residency and I was like, this is my opportunity to first of all start residency. I'd always wanted to work in Kenya since I was training as a medical officer. So, I applied, I interviewed, and though COVID really interrupted the process, we were admitted. My classmate Eunice and I started here this year in January.
David: And so where were you at that time?
Rebecca: That time I was working part-time for a private hospital. So, when COVID started, I took the opportunity. . .Okay, I always wanted to know about public health. I resigned from a medical practice job, and I volunteered in a public health kind of position where I was collecting data about COVID, creating educational materials for non-medical people about COVID with information on how to adapt to the new normal. That was for about a year and a half. And then now once I applied, when I started looking for residencies, I went back to medical practice to keep my skills sharp. I started working on a locum basis at a private hospital, Avenue Hospital. I was mainly working as an outpatient, so seeing a lot of different things, but I think it was a good way to kind of get me back from public health and into medical practice.
David: That's awesome though. This is probably jumping way ahead of where I wanted to go, but I think it's interesting. Have you been part of any research things at Kijabe? I feel like Doctor Kynes always has some sort of research thing going.
Rebecca: Yeah, actually, recently we did we took part in an SOP study. . .
David: What does that stand for?
Rebecca: Surgical Outcomes in. . .? So, it was just about what are the immediate surgical outcomes in a pediatric population where by now, after any given surgery for Pediatric patients we would follow them up for 30 days or until they were discharged just to see have there been any complications and what the complications were? So personally, I was just a data collector, but I thought it was interesting just to participate. In our medical schools, we don't get too much experience with research, at least in my school.
So, even if it was just data collection, I felt very excited to be part of it.
There are a lot of other things we're discussing about starting from January, just ways that we can improve data and make things better, to improve recovery after surgery for our patients.
David: That's awesome. What have you seen in your time in Kijabe? I know you're still newer, but you've done a lot of work in a year. So, what is life like in theatre and what is life like as an anesthesiologist?
Rebecca: It's actually very exciting. I'm really enjoying it. There are days it's a bit tiring because there's a lot of work, we do a lot of surgeries. And you realize, even with the many anesthetists we have, even with us and a bunch of anaesthetist students, the need is so heavy for more practitioners who do anesthesia.
So, you know, with a full list of surgeries, we still feel overwhelmed. And considering I'm not even done yet. . .I'm not an anesthesiologist and I'm feeling the burden, I can't imagine how Dr. Greg and Dr. Matt feel. Honestly, the pressure must be so heavy.
But it's a very fulfilling line of work. I think we participate so heavily on patients' well-being.
I mean, there's putting people to sleep and waking them up. But I think telling someone, “you'll be fine.” You know, “Someone is about to cut you open, but it's okay. I'm here. You know I'm right behind you.”
You know, there's such an emotional aspect that people don't think about when they think of anesthesia. And we are doing a lot outside of just medical practice. So, I've realized it's a very holistic line of medicine. It needs a lot of heart. It needs a lot of even people skills: being patient with someone, being able to talk to someone. And then obviously knowing the anesthesia skills themselves. Because you want to put someone to sleep and wake them up fine.
It's very it's very engaging. It engages your mind. It engages your heart. You have bad days, you know, and surgery doesn't go well. But I'd say most of the time we have very good days. I'd say it's a very fulfilling line of work. I’m very happy with my choice.
David: It's so true, because usually, usually I'm not on your end of the drape when I walk into the theater, but I'm often surprised I walk over there and realize, “Oh, this patient is awake.” I'll be chatting with you guys. You know, if they're doing local, you know, (the patient) can chat with you. They can't really see or talk to the surgeon. But you have to be present for them.
David: I know it’s interesting as the first class of a program. I mean, this is it's a big deal. What do you hope will happen in your coming years and maybe even after your time in Kijabe as far as anesthesia training?
Rebecca:
Well, obviously, I'd love it to expand and expand and expand because the need is there. But I'm excited to participate in teaching as well. I think when you have good teaching, you have good practice. When you have good practice, it means safe care for patients.
I think if every doctor, it’s a skill that you have, if you're trained to teach those younger than you - it's even biblical that you should teach - it's good to disciple each other based on biblical principles, but even the skills that we have, I think it is good stewardship to teach it. So personally, even as they are taking more classes behind us. . .I know it's a lot of work to have all that like on us, like, on Eunice.
I feel like these are a heavy burden for us because we were the first ones. But, I'm excited to guide the next class and teach them what I've learned so far and see how the class is getting bigger and bigger and bigger and then hopefully helping with teaching the anesthetist students, I think it just means that they'll be better care that is being given.
I'm not sure where all of us will end up at the end of the four years, but at least even for the (Kenya Registered Nurse Anesthetist) students that are passing through the program, they only do 18 months, you know that wherever they are going, there's good care that's going to be taken there. So, ultimately, in the grand scheme of things, we are making it better for patient care worldwide. Well, maybe not worldwide, Kenya-wide.
David: Very shortly we'll be at least Africa-wide.
Rebecca: Africa-wide, yeah. Which is still impactful because the need is there.
David: So what is the difference between a nurse anesthetist and a doctor anesthesiologist?
Rebecca: Other than the basic foundation for national statistics, a nurse who either did a diploma or a degree to get their nursing qualifications and then the further specialization in anesthesia, which is normally a post-diploma kind of training. It's just like adding on to whatever they've done already.
But for (us) anesthesiologists, you've finished your medical school, you've done your internship. It’s a full post-graduate training, which affords you the specialist or the consultant qualification. Now there's a lot of overlap in terms of what we cover, but I do feel like for the anesthesiologists, you go a bit deeper because nurse anesthetist training is 18 months.
But for us, it's four years. And within those four years, you go much deeper into whatever you're learning. There are a lot of other extra things that we do. Regional (nerve block) is a big thing for anesthesiologists, which is not really covered by nurse anesthetists. I think we go a lot deeper in physiology, pharmacology, things like emergency management, crisis management. So, you'll find like whenever there's a problem in theatre, most of the time the nurse anesthetists are able to handle themselves. But Dr. Greg or Dr. Matt might have to be called in for a leadership role. So, I think as an anesthesiologist, it’s more like you're being trained to be the next line of defense.
David: Okay. Yes, that's kind of what I've heard from Dr. Barnette. I remember him saying that. So the KRNA, if things go well, they put the patient to sleep, they wake them up, bila shida (no problem). But then when things go wrong, you need an anesthesiologist around. You think broader. And so, you're spending time in the ICU (Intensive Care Unit) this month? You have to do a broad-based study.
Rebecca: For us, even ICU care, like critical care, it's something we'll be revisiting all through our training. We have units in ICU and we have rotations in that multiple times a year. For us there is a Critical Care Exam, an Anesthesia Exam, a Pain Management Exam. So, I think the scope is a lot wider.
David: I'm very familiar with what happens in theater, but what are you doing in other parts of the hospital? You'll do these rotations where you're just learning generally. But then what specifically do you do outside of theatre?
Rebecca: Outside of theatre. . .in ICU currently we help out with seeing the patients, walking them up, and helping with whatever work needs to be done for the patients. It's more like just the general work around the patients. But eventually, we're hoping to help with the teaching because we normally have classes every afternoon. So, helping with the teaching. . .and then once we're in a higher level of training, they want us also to help rounding. Whatever we'll be doing in the theatre, we'll also be doing in ICU. Then of course now there's consulting, especially for things like pain management in the wards for guys who are either post-op or non-post-op.
So sometimes you'll be like, "Yeah, we've had this patient, we've given all the drugs we think we can give, but we don't know what to give next." And that's now when we come in because now we can add additional modes of pain management like the regional I was talking about earlier. So mainly it's that.
And then pre-op assessments for patients who are in the ward. So, you know, someone is just brought to theatre and were like, “No, this person can't go into surgery.” So, it's normally easier to just see them in the ward, assess them, then give the go-ahead from there.
David: And when you're doing that, what are you looking for? Why would you not take somebody into surgery?
Rebecca: I think you're just making sure that you have the best outcome you can get. So, if you have an old patient with many comorbidities, they're not fully optimized. Maybe they have hypertension, they have diabetes, they have kidney failure, and all those things have not been managed well enough. A lot of our drugs in theatre have an impact on all these systems. So, there are times when there'll be an emergency and you'll be like, okay, this patient is not a good candidate, but it's an emergency.
But you always want to do what's best for the patient and you don't want to lose a patient on the table. I think it's normally easier to just advise them your [blood] pressures are not okay. We can do this. The sugars are not okay. We can do this. And so on and so forth. So, you're looking at things that could possibly go wrong and [asking] how I can optimize them before to make sure that we have the best chance that we can have? I think that's the simplest way I can put it.
David: That's great. So, you sound like you're doing a lot of linking with other specialties. Kijabe is a bit interesting in how patients are labeled. Some subspecialties will technically own a patient. So, you say, Oh, this one's general surgery, or this one is orthopedic surgery or this one intensive care. But you guys [anesthesiologists] are crossing over all of those specialties and trying to help anybody, either surgical or needing your expertise. You just go where you're needed.
Rebecca: Exactly.
Rebecca: Like when you're just thinking “Oh, this person might have pneumonia.” For anesthesia, the drugs that you're using, the medication you're using, touches every single part of this person. You have to think more broadly. So sometimes you'll be looking for things. You know, a doctor will look at you and wonder, why are you looking at the chest? I'm just cleaning the leg, you know? But I'm like, “no, this chest is going to hurt your leg,” you know. So, I think it really forces us to look more broadly. I think it's just one way of being thorough. You want to be thorough enough so that you cover all bases because. We are partners in the theater with the surgeons. We want the surgery to go well, but we also want good outcomes for both sides. So we just make sure we cover the bases as they are doing whatever they're doing.
David: That's good. So, you touched on this a little bit. How do you think about medicine as a ministry? How do those connect?
Rebecca: I think it's that you're meeting someone at a point of vulnerability. So, for me, as a medic, this person is completely open to you physically, emotionally. . . they're open. And it's just an opportunity to be gentle, to be kind, to love them because it's not something their relatives can do for them.
Jesus went around healing people, and we're just an extension of that ministry for him. And then even just meeting that person, “I'm scared of going to theater.”
“Okay, this is how I can help you.”
Or, "you're having all these issues with your comorbidities. This is how we can help you."
I think [medicine as ministry] is meeting someone where they can't pass and helping them walk through it.
I think that's just so powerful. I don't think we realize how much power we have and how impactful it is to people, especially after now they are healed and they are better and they're like, “Wow, I could not have done this without you guys.” So, I think it's just like extending those fruits of the Holy Spirit to others and then eventually helping with healing.
David: Awesome. I love that. What is the hardest part of what you're doing right now out of your study and your work?
Rebecca: I mean, as we're getting better and better with the learning and the walking, obviously there's the higher responsibility. We are feeling like we're getting more work. Obviously, in theater, we're getting more opportunities to teach, more opportunities to go into research. So, I feel like it's getting a bit heavier. But I think the worst, worst, worst is when we have bad outcomes.
So in theater or in ICU, of course, I see it a bit more because the mortality rates are much higher. So, I think in theater it's more painful. Like when a patient goes on to a table, they're fine, they're talking to you, and then something happens and, you know, things go south. I think it's very heartbreaking.
And, you know, you audit yourself, you'll audit the team. We'll spend the days repeating whatever happened, kind of just talking through it. And sometimes you don't get an answer. Sometimes you’re just like, “we don't know what happened. We do know what we could have done.”
So, I think that's the hardest bit. And then having even to explain to a family “This is what happened. We can't explain.” It's emotionally exhausting, but there are some things I think we just need to remember. We're not in control of everything.
You can't control everything. You can't save everyone. Not really. We are there to help, but it's not our job to. . . We can't save the whole world. But it's hard.
David: So how do you manage that? How do you deal with difficult things or difficult situations?
Rebecca: We just talk with one another. You just find a coping mechanism that works for you. There's a lot of debriefing we do as a team. I'm fortunate enough to have my husband in Kijabe with me, so I love talking with him after such a bad experience. Then just small things like journaling, and exercising, it's a great way to get things into perspective. I think prayer. Just remembering I'm not in control of any of this. It's not in my hands. And just releasing it to Him. You know, we are servants of the Lord and how he uses us is how he uses us. We are not the ones in control.
David: You're underneath the broad umbrella of PAACS (Pan African Academy of Christian Surgeons) which, now I think they need to add another A (for Anesthesiology) to their name. So maybe you could talk a little bit about that. What is PAACS and then why is it special that you guys are joining the family?
David: First, what does PAACS stand for?
Rebecca: The Pan-African Academy of Christian Surgeons. So, they train surgeons, mainly surgical specialties across the continent. And then once you've done your training, usually you're bonded in a PAACS-affiliated hospital where they see a need for that surgical expertise. They realized we also really need anesthesiologists. So, we've now fallen under that umbrella.
I think what they're doing is special because it's a very different kind of. . .should we say worldview. . . they’re presenting. There are a lot of schools in the country that are training surgeons, anesthesiologists, and other specialties. But PAACS has managed to incorporate our belief in Christ into the program. So, it’s not an extra part of the curriculum, it's inherently part of the curriculum. I think, for a believer, it makes for a more holistic doctor.
I think most universities tend to focus on the theory and the skills someone has. But we're realizing, there's a big emotional aspect to how you handle your patients. There’s a big emotional aspect to how your patients relate with you. And, I think if that's not addressed, you could be the best surgeon in the continent. . .the best. . . speaker. . .but patients can tell how your heart is from how you treat them, how you treat others.
I think for believers, that's where we have a stronger foundation when it comes to what is good and what is bad. How should I treat others? Why is healing important? Why is medicine important? I think it makes a better holistic doctor. Which I think ultimately benefits patients and benefits other doctors even more.
David: What do you see? You were talking about Christian ethics. What are the difficult ethical choices that you guys regularly have to make?
Rebecca: Okay, in theatre, the hardest is normally like, “should we take someone to theatre or not?” Because I think sometimes you really have to evaluate like what's the risk versus benefit for this patient. Because there are a lot of patients who have a lot going on. You know, every body system is doing poorly and the surgeons are like, “they need surgery” and we’re like ugggh.
That’s one, but I think the hardest is normally in the ICU because these are critical patients. Sometimes they're just old, sick patients. They could be very young, very strong patients.
So, you expect young, healthy patients to do better. And I guess most of them surprisingly do so. But you’ll have a number who deteriorate in ICU, and it's very difficult to talk to family and tell them that we've reached a point where there's nothing further we can do. And even just making the decision to, like, stop machine support, I think that is the hardest. Like even bringing up the conversation with family is like, what words do you use?
I'm always in awe of the consultants. I'm normally like, “this is a skill that is given by the Holy Spirit because I don't know how they do it.” It is so difficult.
Patients’ families will break down in front of you and you think how you have to stay calm and you manage to explain everything logically in a way that they understand. Everything in ICU is complicated. So, you explain to someone who has no medical knowledge. . .
Rebecca: But I think just making those very hard decisions about this patient can't continue on the ventilator or this patient can't do this or that. And I'm sure even in Pediatric ICU they probably make such decisions as well. I can't imagine making that decision for a child. It's not easy.
I think. . . we just pray for them that we have wisdom on how to deal with all those things. Because it's heavy, it's a heavy responsibility.
David: That’s interesting. I feel like there is definitely a skill aspect of it. . .there's definitely a walking-through-it aspect. . .but I feel like probably one of the most important things is what you already have, which is the sense of the heaviness and the sense of the sacredness of it, and the sense that “this is hard.” And I think families can see that. They can sense when you care about their loved one. They can tell that a mile away. In some situations, words can't make it better. They can bring some comfort, but they can't make the hard situation go away. But just knowing that you care, I think, is very, very comforting to them.
David: Even the way you're talking about it now, I think is good. . .because you can learn, you can learn skills, but you can't learn heart. And I think you have heart.
David: I didn't think we were going to talk about this, but you would be a good person to ask because you've been around different parts of the hospital. One of the things that I'm trying to fundraise for this year-end is trying to upgrade ICU equipment. What is it like up there?
Rebecca: It's working. I mean, there are days you'll find one monitor, one part of the monitor is working another bit is not. So, maybe it's measuring your blood pressure and measuring your saturation, but the pulse is not working. So, there are times we have malfunctioning of the monitors. So sometimes you're not sure whether it's picking is what is really what is there. They are coping with what they have.
David: The ventilators are similar, right? They work if they're working?
Rebecca: They work if they're working. They don't have one model of ventilator. So they're different ventilators. They all work differently. Each of them is set up differently. Personally, there's one I know how to set up and maybe two or three others I have no idea how to set up. So, you really have to learn how to set up each of those machines.
So, I'd say the staff there are working very well with what they have, but I would say it does need a bit of an upgrade considering the monitoring should be perfect. So, I think it's somewhere where you'd be worth investing in.
You know, guys are fine in the ward, but in the HDU’s, in the ICU’s, I feel the monitoring should be kept up to date. It just means that it's easier to make a decision. It's easier to interpret things. Usually, like if I look at a monitor, whatever is there is accurate. I don't have to think, “hmmm, let me bring the portable monitor and confirm,” because that happens a lot. Like, “Ummm, let me just look for another monitor and just confirm that this is so.” An upgrade would be very nice.
David: That's my hope. We just built these new operating theatres and I knew the entire time, "Oh, this is a great project, but if we do it, it will put a lot of stress on the other parts of the hospital, especially the ICU.”
You have all these patients going through theatre and then where do you put them afterward? And then I guess if things aren't right in ICU, then you just hold them in PACU (post-anesthesia care unit) indefinitely.
Rebecca: Definitely, it depends, if they need ICU care, you keep them in theatre because they have everything we have. PACU is limited. Like if I have an emergency in PACU, it's very inconvenient to get the drugs I need or the equipment I need. But theatre has everything and because you're the one in the room, you know where everything is. So personally, I'd wait in theatre until they tell me we have space. Then I go directly to ICU.
David: It's not ideal either. You're trying to use your surgical nurses to do ICU care, which. . .
Rebecca: Is not great. It means a lot of, like, instruction, a lot of reassurance. “It's fine, we can do this.”
David: For the volume of surgeries and things we're doing, in an ideal world how much bigger would the ICU (Intensive Care Unit) or the HDU's (High Dependency Unit) be?
Rebecca: I have an opinion about this, interestingly. I don't think it's a size issue. I think it's a type issue.
So, I know, in some hospitals abroad, there is a medical ICU and a surgical ICU. So, all patients who are admitted from casualty with medical issues go to the medical ICU. But theatre has its own ICU somewhere, only surgical patients go to that ICU. Which means that the specialists who are there are different. You see, in our ICU, a lot of them are either physicians or hospitalists. . .there's more of an internal medicine background as opposed to other ICU’s in the country where it's normally an anesthesiologist most of the time.
Now for a medical ICU, I think a physician is perfect. For a surgical ICU, I think an anesthesiologist is perfect. I think, considering we are training both, we have both of that now, probably working on a surgical ICU would be ideal.
One, because you don't need as many beds as a medical ICU, but also because it means there's a specific staff with these kind of patients and specific staff for those kind of patients. The monitoring for medical is different from monitoring for surgical.
It also means you don't have to think of “So should I do a 10-bed ICU. Should they do 15-bed ICU?"
You can do five-five and it would still be enough because that's ten already and it's completely different.
It's just something we can look into. . .I'm not sure exactly how it's run. I mean, that's staffing, that's monitoring. . .it's a whole other department altogether. I know the implication financially would be crazy. But, you know, just in an ideal world, it would work really well. Having a separate ICU for the surgeries
David: Hmm.
Rebecca: Yeah. I think Dr. Matt and Dr. Greg have more experience with that from their facilities back home.
David: There are different aspects of all these things. I mean, there's the physical place and there's the equipping part of it, and you just hit on the one that's the hardest, a lot of times: staffing. But, in four or five years. . . right now we only have two anesthesiologists on staff and they are barely able to run the theater on their own. If we had four or five, five years from now, then you could actually have somebody doing the surgical patients. Whatever it looks like logistically, you would have the person being able to do that. That's interesting.
Rebecca: And it's true because the good thing with Kijabe is they're training allied health professionals. It literally has the capacity to staff any new department it can come up with. So, they have ECCCOs [Emergency and Critical Care Clinical Officers where in training you could train ECCCOs, then just add a specific theatre or surgical aspect to the training. That way they go for now go to outpatient and med ICU. Then they would go specifically for surgical ICU, or you just train all of them to know everything then they rotate. I don't know how it would work. But, Kijabe actually trains its own, whatever it needs. So the potential is there, it's easy to come up with something.
David: That's cool. It makes me happy I heard this from you. I've heard people talk about it before, but I've never fully understood: “This would be the implications. This is how it would need to work logistically."
Rebecca: For anesthesiologists, we are defined as perioperative physicians. So, we do get a lot of learning in internal medicine, but not as deep as a physician would go. So even as I'm training to help out in ICU, there's a limit to how much I can know. . .I feel like I still do a lot of consulting because I'm like, "Okay, I have an idea of this, but because I'm not a physician."
But as a peri-operative physician for surgical patients, I think I'd be perfect for such a position because now at that point, everything I'd be doing, I've learned about.
David: That's really cool. What have I forgotten to ask you? Anything else we should cover?
Rebecca: We're excited for the new group to come.
David: Do you know anything about them? Is there a class for next year?
Rebecca: They have chosen two. One is Kenyan, one is Ethiopian. We’re excited. It will be interesting to not just be the two in the department. So, we're excited to get more people.
David: That is a big deal. We currently have funding. I'm not sure where they’ve gotten to on the PAACS side, but I know funding is available for you and Eunice to finish up and I think the goal is to try and always be ahead on funding.
So, I'm sure that I'm sure there will be fundraising going on to try and make sure that a similar thing happens with them. They always just stay ahead of schedule for just to make sure that everybody gets through and does well. And then the long-term goal, I think, is to have what you guys are doing, to have it happening at several other sites in Africa, which would be amazing.
Awesome. Well, thank you so much Rebecca. Appreciate.
Rebecca: Thank you.