Vanovers' Travels: COVID-19 at Tenwek Hospital

Greetings friends,

We are now about 2 weeks into our time here at Tenwek and are finally getting acclimated to the elevation (about 8400 ft above sea level), and the time change (9 hrs ahead of CST). It also takes me (Randy) about this same amount of time to change my thinking and mindset from western outpatient medicine, to Kenyan inpatient medicine – 2 ENTIRELY different worlds. My typical patients here might have any combination of: severe hypertension; thrombotic events like deep vein thrombophlebitis, pulmonary emboli, or strokes; esophageal cancer (very common in this community for unknown reasons); tuberculosis; HIV; meningitis (bacterial, tuberculous, or cryptococcal); poisonings (suicide attempts); severe anemia; any number of different masses or malignancies; or rheumatic heart disease and congestive heart failure. What I am not seeing much of is COVID-19? This has been very surprising to me. I had visions of rampant disease in the major populated areas of Kenya (like Nairobi), but that seems not to have been the case. I thought perhaps the low levels of COVID-19 might have to do with the absence of adequate testing, but I am not seeing many patients with COVID-like symptoms to make me think it is going undiagnosed. Additionally, Tenwek hospital is now able to do rapid antigen testing (which takes about 15 minutes) as well as PCR testing which is sent out to a local lab, and takes about 4-5 days for results. I did see one of the local missionaries last week with an illness which sounded very much like it might be COVID related. Fortunately (for him and me, since I did not have PPE on during his evaluation) it turned out to be some other type of viral syndrome. He reported that he had been feeling achy and having some neck and back pain for a few days prior to being seen. On the day that I saw him, he had been walking up to the hospital and noted some dizziness, lightheadedness, shortness of breath, and headache with nausea. He nearly collapsed, but was caught by another long-term missionary, and assisted up to the hospital where I was called to come and see him. He reported that his daughter had been ill about 8 days prior with an unexplained illness associated with fevers to 103, body aches, nausea, and abdominal pain with diarrhea. She had been evaluated by the pediatric team, and no cause had been found, though she had not been tested for COVID-19. She recovered uneventfully, and then the patient (her father) began to feel ill some days later. At the time that I saw him, he was extremely lightheaded when sitting, and would complain of feeling “out of it” and like he was going to pass out. He also had nausea, some severe left flank pain, but no fever, chills, or urinary tract symptoms. He did not have any nasal congestion or sore throat. He was complaining of a “funny metallic taste” in his mouth, but no cough or chest symptoms other than shortness of breath. He had a prior history of kidney stones on the right side, but a very different type of pain with these stones. Because of this history, and his left flank tenderness, he had an evaluation looking for possible recurrent stones on the left. His chest x-ray, renal ultrasound, and abdominal CT scan were all unremarkable. His lab work revealed a mild elevation of his white blood count (11.5) as well as a predominance of certain types of white cells usually associated with bacterial infection (85% segs). Other than that, everything was within normal limits. He had rapid antigen testing for COVID 19, but this was also neg. (False negatives, and false positives can occur). He received 2 liters of IV fluids, and felt a bit better, but was still very weak, dizzy, and lightheaded. There were no beds available in the hospital (not an unusual situation – some patients wait 2-3 days in the emergency area before a bed becomes available for them), so the decision was made to try and treat him at home in his apartment. He was given a dose of IV antibiotics, and assisted home to his wife and family where he was instructed to isolate, wear a mask around other family members and to push oral fluids and high sodium containing foods (soups, or broths) to help maintain his hydration orally. Fortunately, his wife had a digital thermometer, a BP cuff, and a pulse oximeter to help monitor him while at home. He remained very ill- appearing for several days thereafter, and decision was made to repeat his COVID testing by PCR, and to repeat his white blood cell count. His repeat white cell count had fallen to the low normal range (3.4) and his white cells had become mainly lymphocytes (50% lymphs) – a change which suggested a viral infection rather than a bacterial infection. He continued to complain of this same “funny taste in the mouth”, but did not lose his sense of smell. He never had any cough or drop in his oxygen levels, but continued to have borderline low blood pressures and lightheadedness (BP’s 85/50 – 90/60) with normal heart rates. I continued to monitor him at home for several days, and he gradually began to feel more and more normal. Yesterday, I received word that his PCR testing for COVID-19 was negative as well. After the first encounter at the hospital, where I evaluated him wearing only a mask), the decision was made that only one person would physically check on him at home, and would use more PPE (personal protective equipment – gloves, gowns, face shields, masks, etc.) during these encounters. This was undertaken to minimize the risk of possible COVID- 19 exposure to others. The hospital has also taken extraordinary measures over a short period of time to deal with a possible outbreak of COVID-19 in the community. They have developed 2 new units consisting of about 25 beds total. They have developed safety measures to protect staff and other patients including what are designated green zones (access by anyone allowed- patients and family are typically here to register or check the status of a loved one), yellow zones for “donning and doffing” PPE (limited staff- only access areas), and the red zone which consists of COVID, or suspected COVID patients and staff. No one other than designated staff is allowed in these areas. Tenwek has developed a policy that only staff under the age of 60 can access the red zone and care for COVID patients. These designated staff are only rotated through the COVID unit (CHACU unit), and not rotated through the general patient wards or ICU’s. Consequently, there are 2 MO’s (medical officers) and 2 CO’s (clinical officers – equivalent to a PA in the states) who staff the unit. They work 12 hour shifts, and are on call every fourth night and every fourth weekend). There are also nursing staff who are confined to the CHACU unit (COVID holding and care unit) and not circulated through the general hospital population. They have had about 25 staff members (including some missionary staff) who have come down with COVID over this past 6 months – fortunately all have survived and recovered uneventfully. Bomet County, which is where Tenwek is located, has only had about 250 confirmed cases. The entire country of Kenya has reported ~99,000 cases and 1,726 deaths thus far. Recent case numbers have been declining and about 100-200 new cases are now reported each day (country wide). At the peak in November, they were seeing about 1500 new cases per day. I don’t really understand why Kenya has been relatively spared compared with the US, but fortunately this seems to have been the case. At Tenwek, the population is mostly rural and spread out, so case numbers are relatively low. The CHACU unit now has about 8-10 patients on any given day. I feel so fortunate to have received my first dose of vaccine shortly before departure from the US…this was very comforting to me after my potential exposure as described above, and was one of the reasons I was allowed to continue to monitor and care for him (being over 60 myself!). I thank God that I (we) remain under His protection and have continued to be healthy. While Tenwek Hospital has made great strides in becoming a center of high technologic, as well as holistic care, it remains very limited by US standards, and would be a frightening place to become seriously ill. Hopefully, by God’s grace, we will never have to find out what that would be like. Thank you for all your prayers and well wishes. We look forward to being home again soon….though perhaps we are safer here?! May God bless you and all your loved ones.

Randy and Marilyn