Linette

David: I want to talk a little bit about the hospital, but I'm also curious about your life. 

So first, just tell me your name and what you do at Kijabe Hospital.

Linette: My name is Linette. I'm a medical officer, general doctor at Kijabe. I work in the Internal Medicine department in general wards.  When COVID was here in COVID ward – now it’s respiratory center, and in ICU/HDU [Intensive Care Unit/High Dependency Unit] Unit.

David: Why did you end up with adults?

Linette: [Laughter]Well, I love internal medicine. Anything to do with Internal Medicine, I love it. Whether it's an adult or a baby. I just love it. I feel like it's easier and maybe it's easier because of where I went to school. . . Where I went to school there's a lot of lifestyle diseases, less infectious diseases. 

David: When you say lifestyle, what do you mean?

Linette: Like hypertension, diabetes, things like that, which is most of internal medicine. And so, it was not like Kenya where you have infectious disease to think about. I feel like that was my foundation when I came for internship, I found this safe place, this comfortable place in internal medicine. 

So, it's like, oh, I know that. It's not new to me because I've seen it, and that just made me love it more and more because I felt like I know that and now I can build on that. 

I mean, it turns out you don't know anything.  You don't know what you don't know! 

But it’s fun to build on that one. Yeah. So [Internal Medicine] is my favorite one. 

And why adults? I'm very emotional when it comes to kids, and my pediatric rotation was full of a lot of tears. So, I was like, “No, I need to like, get myself together and be a doctor and look like a human. . .what?  Hard-board or something. . .like nothing is touching me, I'm just okay.” But inside I'm all mushy. So, I feel like kids really remove that from me. And then adults are like, “okay, I can cry about this later, let's deal with it now.” But then kids, cry now!  [Laughter]

David: That's great.  You did your you did your internship at Kijabe?

Linette: Yes. Yes.

David: Tell us about medical school. How in the world did you go to school where you went to school?

Linette: I went to school in Russia, the Russian Federation. And it was just it was a miracle of sorts because I had no idea that I could go to school in Russia. In fact, I didn't even want to be a doctor until my last year of high school when I feel I felt the Lord telling me to be a doctor. And I was really against it for like a month. I spent a month arguing with God in my closet. Like, really? You really want me to do that? I've never wanted to do that. I want to be a lawyer. I want to be a scientist. I want to do research. I had all these other plans.

David: Anything but medicine.

Linette: Yeah, anything but medicine. Everyone wants to be a doctor, but who is going to take out the trash?  Who's going to be the mechanic? Who's going to be the engineer?  I don’t want to be a doctor, everyone's going to be a doctor. 

 

It turns out not everyone became a doctor - I became the doctor! God has a sense of humor because the thing that I was fighting so hard not to do turned out to be the thing that I do the easiest.  

I went to med school and God make it made it so easy for me to learn and to understand the concepts. . .to understand physiology and how the body works and what drug goes with that. So, I was like, "Hey, man, it's good to follow what you feel God is saying to you." And boy, am I glad I did that.  

And then Russia. A friend of mine visited from Russia. I hadn't seen her for years. She was in second year [of medical school]. She told me Russia is good.

David: She's Kenyan?

Linette: She is Zambian. At that time, I was living in Botswana, that's where I grew up. So, my Zambian friend comes home for holiday and I'm like, "Hey, long time, I haven't seen you. It's been years. Where have you been?" She's like, "I've been in Russia." What are you doing? "I'm doing medicine." And I'm like, okay, that's amazing. I hadn't yet agreed with this whole plan to do medicine in my heart, but I thought, "This is a good like idea to look into Russia as a school option."  I didn't want to stay in Botswana to do my university. So, I asked her questions, and she said that teachers are good, the groups are small when you study so the teachers can follow you very closely. And she said everything except that they don't speak English. [Laughter] And I feel like God literally blinded me to that because I asked every question except, "What language do they speak?" I mean, I know there is Russian, but surely, surely, they speak English, right? They're white!

No, they don't. And I found that out when I landed in the country. [Laughter]

So, I out of curiosity, I study Russian. I'm so excited.  I’m going to Russia! And then, I land in Russia and it turns out I have survival skills now. I decided, "Well, I'm here, so I have to keep a positive mind about it and learn it as fast as possible so that life can get easier." And that's what I did. So, I learned it and life got really much easier.

David: And so that was how long? Five years? Six years?

Linette: Yes, six.

David: And then. So, you're from Botswana. How did you get to Kenya?

Linette: I'm from Kenya.

David: Okay.

Linette: I was born in Kenya. My parents are Kenyan, my dad is a civil engineer.  When I was five, my dad applied for a job with the government of Botswana, and he got it. He moved to Botswana to look for greener pastures. Then the family followed him. So that's where we all grew up, me and my sisters, except for my youngest sister, who was like a bit young when they moved back to Kenya when I was in third year in Russia. When they moved back now, home became Kenya again. So, when I finished with Russia, I came home to Kenya.

So now I had to learn a new language, Swahili [laughter] because, I know how to say hi, but everything else is a blur because I was five when we left. But because I had learned Russian, I was like, "This is nothing impossible. Surely it's just a language." And now I speak it fairly well. I can speak Swahili and no one knows I'm not really Kenyan, but when I speak English, they know because my accent is not Kenyan.

David: Yeah, Botswana - that's like the usually the voice actors and people like on TV in America, like that's the pure like, classic African accent.  So, like in Disney movies it's always a Botswana accent.

David: And so, what were challenges? Did you have time off in between in between finishing medical school and starting internship? How did you end up at Kijabe?

Linette: I had a whole year of nightmare. None of my papers were Kenyan, so I went through such a terrible time. I went to try and verify my degree and they said I had to verify my high school certificate. And then when I went to try and verify that, they said I had to verify the primary school certificate. And most of that was like, we need a physical letter from the governing body in Botswana. I have no family left there. How am I going to get like a real letter from them? But thank God for friends. I asked a couple of friends to help me, and they sacrificed time from their jobs to help me chase down that.

It took a whole year from the time that I came back to the time that I started internship. And even after doing the whole verification thing, turns out you don't just do internship, you do pre-internship, which is like an internship, but then it doesn't count. And then you write board exams. So, I did that. And then just as I was about to ballot for a government place in the internship, a cousin of mine asked me, 
“have you tried Mission Hospitals?”  She had worked for Mission Hospitals and she feels like they're great.

Linette: I was like, "I've never thought of that. What's that?"  She told me, "the last interview is next week, Monday, find a way there." 

So, I found a way there [laughter], showed up, did the Kijabe interview and I fell in love with Kijabe just from talking to the doctors on the panel. Dr. Arianna was on that panel that day. I was I was so in love with Kijabe. I was like, I'm done. I'm going to Kijabe!  I didn't even interview the other two places. I'm going to Kijabe - I'm not going anywhere else.

So, I went home all happy. I'm like, "I'm going to Kijabe, I'm going to Kijabe!" I don't know, that was just I was just so sure. I fell in love with this place before I came here. And since I came, I've not been able to leave since, like you think about going anywhere else and you're like, okay, so what's life going to be like there? Nope, I'll stick to this one.

David: What particularly do you like about it? 

Linette: I love the compassion with which people approach medicine.  I mean, there is science and there's evidence and there's all that. Anyone can get that anywhere, you know? But there's a human touch and aspect that you can't buy anywhere. You can't buy that. And then a lot of these doctors are Christians. . .and missionaries, they're here not because their homes are not comfortable, or their countries are not good. 

I mean, I've been a foreigner. I know it's home that's always best. It's very uncomfortable to be a foreigner sometimes, but the [missionaries] are here because they feel like their call to humanity is higher or greater than their comfort.  I feel like because God told me to be a doctor, it's great to be around people who take medicine like a calling.

There's also the evidence-based approach, you know.  It's not quack medicine, it's not abracadabra. It's, "Okay, I read this paper and it says, 'This approach is better for this disease.'"

And that's what we do. We do that because the best idea wins.  The best idea is tested. It's tried. It's been through trials and studies and that idea wins. So, every protocol changes according to the idea, the evidence that has come up.

The system of correction for mistakes, audit, is taken very seriously. Audit helps us change protocols, change our approach. It's one thing to say, "we will do" and then it's another thing to actually do. It's a culture that goes on from the highest doctor to the lowest staffer.  Even a patient assistant adheres to the protocol. That's a cultural thing that you can't buy. If people's mentality is "I'm here to get my money and go," then they would never do that. But the fact that we say something in a meeting, and it actually happens - that's wonderful. 

David: Wow. That's awesome. I love it. So, internal medicine. . .What's good about it and what's hard about it? What do you love and what's the most challenging?

Linette: Let me start with what's hard. What's hard is at least once or twice a week, there is this one patient, who, I'm like, "I have no idea what's going on here." And then, once in a while, there's this patient who everyone is like, "I have no idea what's going on." 

Really? That's mind boggling. But then that's also why it's great because every time you think you know, you don't know.  You don't know what you don't know. But then, every time, you find out there's more to learn. I love that opportunity to grow.  

I like places where I can be put under pressure to grow.  There's no bigger force or pressure than the feeling of "I don't know."

Then there's this culture of mentorship that Kijabe has. I have awesome seniors who don't make me feel dumb for not knowing. So, when I don't know, there's always someone a phone call away who might know. And if they don't know, they're so honest. I love that they're so honest when they don't know. And they're always willing to offer advice on, "have you tried this, and have you tried that and how do you check this and that?" Then they teach you how they think so that you can be a proper mentee. I love that. That's what I love about internal medicine in Kijabe. I don't know about internal medicine in any other place, but here, it's like you're free to be dumb if you're dumb and we will help you get smart.

David: I don't think that's a problem for you. You're very humble. Doctor Tony Nguyen is the head of internal medicine right now, and he was telling me that. . .

Linette: He's my boss and he's awesome.

David: Oh, that's great. He was talking about ventilated patients, that a lot of your patients are younger. Why do patients come to you? What are their issues?

Linette: Well, our vented patients are younger, and most of that is because of our resource limited setting. Because of our resource limited setting, we can't afford to intubate everyone. So, our protocol favors a younger patient with less chronic disease going on. It's very sad that we have to make that decision, but we only have a very small amount of resources - in this case ventilators.

David: So how many do you have that are working right now?

Linette: We have five good vents. 

David: I think your definition of good is different from mine.

Linette: Like, it keeps the patient alive. That's good enough.

David: So, that's the distinction. There's actual good, because you have some good [ventilators] and others from 1953 and it's a small miracle. . .

Linette: It's working. It's working. (laughter)

David: But that makes me very nervous.

Linette: It does. It does. But then we live by faith. I mean literally surviving on small miracles. So, there's two really, really good ventilators that have this nice screen.

David: The GE ones?

Linette: Yeah. They have all these screens that you can read. And then there's these [old] ones which are guessing some of the stuff in the background. 

David: It's totally manual, right? You have dials, you can adjust, but there's no waveform, there's no tidal volume, you're just. . .

Linette: Guessing. There's nothing to see. It's just put in the settings that you want and hope and pray that that's it. Then if that doesn't work, you try something else and see if that works. And that's how we live. Imagine.

David: Yeah, not that that's not good, but that's what I'm hoping we can improve on someday.

Linette: If I have five solid ventilators, I think I can depend on. I mean, I think they can save five lives. 

David: And so, you're saying you can have protocols for younger people. 

What about - I don't know if you call it a dance or juggling - interactions between different departments work because? I mean, patients are surgical or medical somewhat, but there's a lot of overlap.

Linette: Yes. It's a lot of teamwork that's required because a lot of patients in the ICU are surgical. But then if they're in the ICU, they're your patient [medical team]. They are surgical, but they’re still yours. And that [relationship] needs a lot of communication between us, a lot of understanding, because sometimes we see with our eyes the medical stuff and they see with their eyes, the surgical stuff.  And we don't see what they see, and they don't see what we see.

So, every time we make decisions, it's important to like double back and ask them, "Okay, we want to do this. Is this going to affect what you are doing in any way? Is this going to harm the patient instead of help the patient?" Because sometimes you might do something and maybe cause bleeding or maybe it does something that we didn't intend to do, but the surgeon would have known that, and we didn't. So, it takes a lot of teamwork to survive a patient in ICU.  

Linette: Sometimes when we are admitting patients, we feel like this patient might need intubation and we might not be able to give them that resource, we try our best to refer them at the door before they even get to the point of deteriorating and needing the intubation. We just tell them, "Look, it's not looking good.”

Usually, it's the family we are talking to because [the patient] is so badly off, and we tell them “It’s not looking good. It's likely they're going to need intensive care. We don't have room, please go to another place.”

Some of them refuse. Oh gosh, some of them refuse. They're like, “we don't have anywhere else to go.” 

Those are tough because they end up staying in Casualty forever. And then we end up like creating an Intensive Care Unit in Casualty because you can't just watch someone die. That's a hard thing. And then some of them die. That's the painful part because you're like, "If we had this, they wouldn't have died," but we don't.

David: Do you have a sense of what it would take? I mean, we want to get we want to get some new ventilators. We want to get ten, maybe more, high dependency unit beds. What would it take to treat everybody you think we should be treating?

Linette: Oh, my gosh. A lot of money!

David: Well, not in the money sense, but how many HDU beds? How many ward beds? What would it take to do everything you would love to see us doing?

Linette: That would be crazy, because, if I compare it to what other hospitals are actually achieving, they can have anywhere from 20 to 30 or 40 ICU beds and we have 5. So that's a huge dream for us. 

And then we have ten HDU (High Dependency Unit) beds. You can imagine if they have 20 ICU, they have like double that for HDU and we have only 10. So, it's going to take that much more muscle. 

Then the other issue is staffing, because we are so few in our department and a lot of our people are missionaries. It's wonderful because they are here to help, but then they can't always be here to help because they have their homes to go back to. So, we have a lot of visiting doctors who come in. Oh my gosh, when they come, we're like, oh, we can breathe a little bit, you know.  We breathe for like a month. And then they go and then we're dying again. 

We have ECCCOs who are in ICU every week.

David: What does that stand for?

Linette: It's Emergency and Critical Care Clinical Officer. They are clinical officers who have a higher degree in critical care and emergencies. They're awesome. Awesome. They run the ICU very well. A whole ICU really depends on an ECCCO. If the ECCCO is good, they respond to the emergency quickly. They call the doctor quickly. And they a lot of times you get to [the patient], they're already intubated.  They are so good. They respond to emergencies very, very quickly. 

So, there's always one just one in a whole week who does the day and then one in a whole week who does a night and then one in a whole week who does casualty. If we were to ever expand, I think more beds would be overwhelming for one ECCCO. 

And sometimes we have two because there's one and then a student. But then sometimes that could slow the [senior] one down because they're trying to do teaching, you know, like they're trying to show the other one. So that would take more doctors, more critical care nurses who by the way, are so awesome. 

David: And there's training, there's a lot of training going on. This is one of the things I look at. I think, "five beds." There's the patient side. There are more patients who need help. 

But then the training side, Oh my goodness. We have a critical care nursing program. We have the emergency and critical care clinical officer training program.

Linette: Yes.

David: And when I just look at it, I think we need to take care of more patients so they can, to use an exercise term, do more push-ups.

The more patients they see, the better they will be coming out of school.

Linette: It's much better for them.

David: And then you're also taking the nurse anesthetists. They come through.

Linette: On rotations, higher degree nurses doing their rotations and the anesthesia residents and surgical residents.

David: Oh, and surgical. So that's part of their that's part of their residency?

Linette: Yeah, there are a lot of learners, actually. Our teams are more than the patients by far. By far.

David: That's at least 50 learners in a year. 

Linette: They could be more, because per week, it's crazy. 

The last time I was in the ICU, I had three ECCCO students and three KRNA’s (Kenya Registered Nurse Anesthetists) and one more intern and two or critical care nurses. That's ten learners. 

And then if you're on the rotation, you have to teach the ICU curriculum for that week. 

David: So, you're doing that teaching?

Linette: Yes. Yes. I teach. Right now, I took a break because I've been so busy with my family, but I teach physiology in the school.

David: Oh, for the nursing students? 

Linette: For the clinical officers.

Linette: I teach human physiology.

David: Awesome. That is a lot.

Linette: Yeah, it is. That's why I, like, put a pause on it, because I'm like, “Let me just have a baby first and then I can think about it.”

David: Yeah, that's awesome. How old is your little one?

Linette: He's turning one [year old] this week. 

David: So, you're entering a new phase, you're starting to sleep. And you're also starting to, realize, every second there's more trouble.

Linette: He can get into. Yes, I'm battling chronic fatigue. He's such a handful. He's all over the place. And then he just discovered how to walk. So now it's like, "get everything out of the way." And just when you think you got everything out of the way, he discovers another one.

David: What would it take to build a proper ICU?  

That will be a phase-three of the hospital master plan. 

This year there will be a new oxygen and facilities plant that they're calling an Energy Center. That will go It will be just outside of Wairegi [the men's ward]. That's part one. 

Part two is the new outpatient center. 

And then part three will be where outpatient currently is. They want to build a huge building that will be maternity, internal medicine, ICU.

I think it'll take that [building] to get to 30 or 40 beds. But I'm hopeful that we can figure out how to do something substantially more in the near term. 

If we get equipment, it can roll where it needs to go.  Knocking out walls and things like that are permanent, but equipment can follow the need. If it needs to go to Centennial [ward], it can go to Centennial. If it needs to go wherever, it can go wherever. So, I hope I hope we can do a substantial expansion this year. Because it's important and it needs to happen for you guys to be able to do what you're good at.

Linette: Yeah. And now we have a renal unit, so we have, super-sick patients who we used to refer because we didn't have a renal unit. Now that we have an actual dialysis center in our hospital, we get called more and more into the unit because they code on the dialysis bench and we have to go there and resuscitate. 

That's an ICU patient.  They cannot be anything less. 

If you resuscitate, and then you don't have a ventilator, you'll just be bagging and bagging and bagging and you're like, "okay, I'll be the vent for now." But then, "how long am I going to do this? Are we going to get an ambulance? Are we going to go to another hospital?"  

Most of them don't have the money to go to a hospital with an ICU. Kijabe is so friendly, in terms of ICU cost, on your pockets. So, you tell them about any other hospital in the family is like, "no, we can't afford that happen."

David: Do you have to save ventilators? You have that dialysis situation. Do you have to reserve ventilators for surgical patients? Like if somebody knows something bad just came in, they're going to surgery.

Linette: All the time. Yes. Every night I'm on call, I'm like, "how many ventilators do we have?" And the ECCCO tells me we have three vents. And then they're like, “the surgery team called ICU and they said that they're taking in a complicated case, and they want us to save a vent."

So, if I get any emergencies overnight and I had four vents and I'm saving that one for the surgical patient.  If I get any anything in casualty that needs an intubation, I can't accept. So, I have to refer. And that's terrible for those who come crashing because they crash, and our reflex is to intubate. We don't even think, we just intubate. And then suddenly somebody is bagging and we're like, "we don't have a vent."  

Sometimes we end up having to give away the vent we have reserved for an emergency, and that causes a whole chain reaction of problems because now the surgeon is angry at you because they saved the vent for the patient, and they've already cut. And you're like, "let's pray to God that you come out of anesthesia."

Yeah, it's just a jumble, it's just a mess on those bad nights. And then sometimes we have to quickly extubate someone who we didn't plan to extubate today. Maybe we plan to extubate them tomorrow, and we're like, “maybe tomorrow they'll be able to get off the vent,” and then we're like, "Okay, you need to breathe for yourself now because we're coming off now."

But you see, that's a problem because you're extubating prematurely and you're like, “fingers crossed, legs crossed, please breathe.” And then they breathe, and you say, "Thank you!" 

David: So how do you manage all this emotionally? 

Linette: That is just it's painful. It is very painful. Sometimes there is moral injury that comes with denying the vent to some patients because you're like, “if I had intubated, I am not 100% sure that you wouldn't have made it.”

 

I'm just basing this decision on your co-morbidities or your other diseases and the fact that you have significant disease.  

There's this other [patient] with less significant disease and that you are likely to not make it. So that's a bit hard. 

David: What do you do with that? Like, how do you how do you process this?  How do you not explode?

Linette: Our culture in the ICU is when you have a really tough time, we debrief, we call the chaplain to come talk to us, or the palliative team. They're very good at counseling staff members about "What are you feeling about this? What are you feeling about having to extubate this one? What are you feeling about having to do this?"

And everyone opens up their heart and says, "Well, I feel like crap, like this is terrible."

And, well, I have a good husband at home and he's like a doctor now because I take all my stories to him. So, I just offload on him and he's a very good listener. So, I feel better because I have that at home.  I have good support at home. 

David: I love that. 

Linette: Yeah. It's a tough journey, but it's also fun because we see people and its life changing. It's the difference between life and death for someone. So, our extubation days are really good. Like, "Yes, you did it, we saved one! And then 10 million more to go!” Always celebrate the small wins.

David: I love that. Awesome. Thank you so much, Linette

Linette: Thank you for having me.

David: Appreciate, you’re amazing.

Linette: Thanks.