Emergency Care Growing in Kenya

I have just attended two days of the Emergency Care Symposium at Safari Park Hotel. It was running from the 29^th to the 30^th of June 2017.

What many of you may not know is that in my ‘previous life”, I was an emergency care doctor and was very passionate about it. Some have even gone as far as saying that I was good at it! Though I have since moved on to Lifestyle Medicine, as I felt I would be able to have a bigger impact there, I remain passionate about Emergency Medical Care, and this conference was totally enjoyable for me.

This was the first conference of it’s kind in Kenya, driven by doctors, nurses, clinical officers, emergency medical technicians and others who are very committed to see Emergency Medical Care grow in Kenya. Under the stewardship of Dr. Benjamin Wachira, the first Kenyan Emergency Physician living and working in Kenya, the team has been able to bring all these professionals together, including even bankers and the government, and teams from as far off as Uganda, South Africa and Somalia, and put together an amazing symposium that was considerably oversubscribed.

It may surprise most people to realize that of all the fields of medicine, Emergency Care is one we are all going to need, most likely directly and personally within our lifetime, but definitely indirectly through a relative or loved one. Yet, the Kenyan Medical Board has only recognized Emergency Medicine as a specialty in 2017 thanks to Dr. Wachira’s dogged determination!

Emergency Medicine is that discipline that trains an already qualified doctor in how to recognize, treat to a very high degree of technical competence and/or refer appropriately acute emergency cases. These include everything from accident victims, acute illnesses such as malaria or pneumonia when they proceed unchecked to the point of being a threat to life, and other unusual occurrences such as drowning or chocking. Emergency Physicians are the doctors we all loved to watch in the series ER. The reality is that without the scores of highly trained Emergency Medical Technicians (EMTs), nurses and Clinical Officers (COs) out there, an Emergency Physician would be handicapped and almost useless.

One thing that has really impressed me during this conference is the manner in which so many different professionals have come together to grow this new industry. The reality is that a mature emergency system involves all manner of professionals, and cannot stand on any one person or group. With this as the inaugural symposium, we can expect a bright future for the Emergency Medicine Kenya Foundation and the sector at large.

Something that stood out for me at this conference was when Professor Lee Wallis, Dr. Wachira’s teacher and mentor, gave his keynote address. In typical professor fashion, his bird’s eye view of the sector was enlightening and humbling. He noted that in Africa, the care that will make a difference is low cost, involves training a wide selection of people in emergency care skills and not in degree courses, and working with policy makers and government towards free emergency care for all. It was clear that he carries the weight of the inequity of the sector on his shoulders and I was almost tempted to console him. During a personal conversation on the last day of the conference, he mentioned that he strongly believes we have to work smarter to identify that person who is very sick before they get worse and to the point of needing emergency care, such as when one has a heart attack. And of course, it is possible to do this.

It was exciting to learn of the 18-month diploma program in Emergency Care for COs being offered at Kijabe. I have been involved in hiring COs and I do know many of them are unemployed, or working in call centers and other places. It is such a waste of resources, in a country that is grossly understaffed in the medical facilities. Knowing these emergency trained COs will be out there is personally reassuring. As a doctor who has worked in the emergency field, I live in fear of personally suffering an accident in rural Kenya. However, there is now light at the end of the tunnel. 

Interestingly government was very well represented. We were all surprised to learn from Professor Lee that our legislation is much more advanced than South Africa’s. We heard in details what the law stipulates, and policies that are being developed in the sector. We are certainly headed in the right direction, and we pray that implementation will be fast and efficient.

The Emergency Medicine Kenya Foundation has worked on a lot of resources to grow the sector, which are freely available on their website- http://www.emergencymedicinekenya.org It is actually mind boggling how they have done all this in so short a time. It smacks of a lot of personal drive and sweat from a handful of individuals. I salute them. I have always felt that Africa needs homegrown solutions to our problems, and I applaud those pioneers who are championing this and other movements. As a people, we need to mature beyond the crippling desire of personal achievement and aggrandization and instead work to make a difference and leave a legacy.

If anyone came across anything over the last two days that they would like to criticize, I would urge them to hold their tongue, sty calm and do something to make a difference. Well done Emergency Medicine Kenya Foundation, and keep up the good work.

Why The Ostrich Has a Small Head?

Blogging has brought me into direct contact with debate, a necessary enterprise if I am to understand people’s real concerns. I recently had a discussion with a group of people. A young, urban, professional and very intelligent lady helped me understand where many of us find ourselves. Given my background, I had before this found it very difficult to comprehend what even my wife was trying to explain to me about the challenges of being a healthy Kenyan.

This lady had never read my blog, but due to the debate, she got online and rapidly went through both articles. It was quite clear to me she was rather uncomfortable, as she said nothing for quite a while as other debated. Finally, as the debate was wearing down, she stated that she is thoroughly confused (and I suspected a bit disgusted) by all the varying opinions, many of which she rightly stated come from medical people themselves. Whereas some will advise us not to drink alcohol, others put a “healthy” cap on what is ok. Is it brown rice or white? Is it brown bread or white? Is brown bread whole bread or is it colored white bread? Are we to avoid smoking if we want to ensure we don’t end up with cancer? “Then why did my uncle live to the ripe old age of 81 despite smoking all his life?” Are we to have a yearly medical or not, and if we’re not sick, why should we? If we do not, are we likely to be diagnosed with ovarian or other cancer later in life and pass on as a consequence? All these questions she raised in rapid succession, and promptly declared that she will follow her grand-mother’s advice, “be happy, enjoy life, live long!” This was clearly justified given that her grandmother is in great health, and obviously has great genes. It took me a while for the message to sink in, but incidentally I’d heard it before from so many others.

Our societies are in a sad place. We are constantly bombarded by information. How many of you remember a certain TV advert from the 1980s (On Kenyan TV)? It was one of the most mouth-watering moments I have ever seen on screen. It involved “chapatti” and a specific cooking fat that was then universally used to make chapatti. The use of this cooking fat would alert the whole neighborhood as to where this delicacy was being made, mouths would water & stomachs would convulse. The TV advert would rush these memories into conscious thought, even without the smells! In the face of such powerful messaging, is it surprising that we are confused? Is it not amazing that only 20 years later, this product was almost out of production due to its unhealthy nature?

Policy makers have played a leading role in causing this confusion (we medical people are included here). The reasons for this are many and varied, far too complex for this simple discussion. The question I want to raise is what can we do about this? Are we going to burry our heads in the sand “Ostritch” style, while we silently pray that the bullet called chronic disease whizzes past our exposed uppers? When we are carrying out our day jobs, and we come across confusing “facts”, is this what we do? I think not! We square our jaws and get in the mud, plod around until we come up with conclusive, and accurate answers that enable us to achieve our desired results. Why can we do this for our employers, but not for our own health? Without health, can we even work for our employers?

It touches me deeply when I come across a confused soul. Such a person has an open mind, but the heart is weary. We all go through this. I am not looking to change so many out there who are bent on self-destruction; what I hope for is to gently influence those that truly “do not know” into joining me in this journey of discovery. I don’t have the answers, but I am willing to share what I am learning and open it to debate and discussion. Let us work together and learn to be better, if not for our own health, then for that of our children.

Therefore, dear lady, have a look at this: Sugar, The Bitter Truth! This is a great place to start (you will need an hour, and watch it with those that you care about. Don’t let the technical jargon jar you-its only about 15 min). Next time I will talk about this You-Tube video), as well as give a reading suggestion. I hope I have caught your interest. 

Bite-By-Bite Grave Digging

Ach! Blogging is hard work! I’m discovering it is so easy to throw around opinions and sentiments to all manner of people around me, but it is truly challenging to think about what you’re planning to say, revise it in your head and come up with something sensible. This is what blogging is forcing me to do.  But then I wonder, has this got more to do with human nature than the demands of blogging? Do we just inherently like things easy and simple, myself included? Case in point: A young man of 46 has visited the casualty department because of a headache that has been bothering him for the last 2 weeks. As part of routine examination he is noted to have high blood pressure. After a comprehensive review, and hopefully a few more visits, he is diagnosed to be hypertensive (high blood pressure disease). As part of his management, and on top of daily medication (expected to be used for life), it is suggested that he needs to pull back the throttle on his lifestyle, and gear down from the fast lane. Practically this involves less stress, less eating of rich foods, less drinking of alcohol and coffee, more play, more relaxation, more fruits and vegetables and more drinking of plain water. Sounds simple enough? Then how come, one year later, this same young man is struggling with the basics of this plan? One year later, he has actually added weight, and whereas last year he was 20 kg over his ideal weight, now he is 25 kg over his ideal weight! How can such a ridiculously simple plan be so incredibly difficult to follow?

Lets review some very simple mathematics (please note, this is not rocket science, all this information is available for free online & I have put in appropriate links). Lets call this man Dennis. He is 170 cm in height (about 5 feet, 7 inches). He now weighs 97 kg. This puts his Body Mass Index (BMI= Weight (kg)/height x height (meters)) at 33.5. This is known Class 1 Obesity. With his ideal BMI being maximum of 25, his ideal maximum weight should be 73 kg.

But how does all this happen? Let look at his typical week.

He wakes up at 5.00 am to make sure he leaves the house by 5.45 am otherwise traffic will mess his whole day. He does not have breakfast. He will be back home at about 10.00 pm on a regular basis. This is after various after work meetings that he feels he cannot avoid as a senior manager. During the day he will be at the office from 7.00 am and will leave at 5.00 or 6.00 pm to go to a nearby local bar or restaurant, and while he waits for traffic to reduce he will have a meeting or two, some formal, most informal. He spends 90 % of his day seated.

His food intake looks something like this:

	Weekdays				Saturday
Time	Food	Kcal		Time	Food	Kcal
9:30 am	1 Cup Tea with sugar	195		7:00 am	4 slices brown bread	352
	1 Mandazi	128			Jam	76
					Margarine	100
					1 cup tea with sugar	195
1:00 pm	300 grams Ugali	234
	Sukumawiki	120		10:00 am	1 cup tea with sugar	195
	Quarter chicken stew	220			Ham sandwich
	1 glass fruit juice	125
				1:00 pm	Rice	420
4:00 pm	1 cup tea with sugar	195			Beef stew (200 g)	560
					Vegetable salad	150
7:00 pm	2 beers (lager)	300
	Nyama choma (300g)	840		4:00 pm	1 cup tea with sugar	195
	Kachumbari	25
	Ugali 200 grams	155		7:00 pm	3 Chapatis	500
					Ndengu stew	100
	Total Daily Calories	2,537			Fried beef (200 g)	560
					1 glass fruit juice	125
				10:00 pm	250 ml Whisky	700
					1200 ml coke (mixer)	474
					Nyama choma (300 g)	840
6 Wk Days	6	15,222			Total Saturday Calories	5,542
		Total Weekly Caloric Intake 20,764

For simplicity’s sake we’ll assume he eats the same food 6 days of the week and that he drinks 2 beers daily (of course some days none, while others 2 to 6 beers). We shall also ignore the occasional family party where as we all know we over-indulge, and the occasional corporate buffet where we eat every item served, and those amazing deserts (that can pack a whooping 800 Kcal per serving). Note that though he doesn’t eat fruits, he does “try” in the vegetable department.

For his weight and height, his daily requirements (Total Daily Energy Expenditure) to maintain his weight (not gain more) are 2,328 Kcal. This translates to 16,296 Kcal per week. Here we see he is eating an extra 4,468 Kcal per week. All factors remaining constant, this translates to a gain of 0.58 kg per week or 30 kg per year! By just looking at caloric excess, would this man expect to get better or worse with time? Most likely his degree of obesity will increase, he will develop insulin resistance (pre-diabetes) and ultimately diabetes. This kind of caloric excess is now definitely known to be associated with obesity, diabetes, hypertension, heart disease, stroke, arthritis, gout, sleep apnea, asthma and various cancers. Even without looking into his lack of exercise, unhealthy work habits, stress level and poor quality of life, we can see how food is killing him. He is not alone in this dilemma. Even for those who don’t smoke or take alcohol, the caloric excess can be clearly demonstrated. With our current lifestyles, caloric excess is a constant reality. Not many can be directly blamed; most of us just don’t know enough to know any better.

We have to think long and hard about what is ailing us as a people. Is it a bad attitude or just lack of understanding? What role are medical professionals playing, and more importantly not playing? I am not about to suggest we all start counting calories, there is an easier & more practical way to get healthy, as we shall see over the next few weeks.

I would argue that any man (& of course woman) who demands of themselves to like things “not simple”, to follow the more challenging path, is one who will ultimately find success and great reward. We all need to be involved in learning how today we are digging our own graves a bite at a time.