The Accident and Emergency section of the Kenyatta National Hospital.

The Accident and Emergency section of the Kenyatta National Hospital.


Inside KNH’s busy Accident and Emergency wing

What you need to know:

  • The lean team working on the night shift is dealing with cases of medical trauma and high drama around the clock as patients troop in without referral letters.
  • The nurses at the station do their report at the end of the night. One had been in charge of administrative issues and the other one was coordinating the referrals.

It’s 9.23pm.

Evelyne Achieng lies writhing in pain. Her voice pierces the cold corridor at Kenyatta National Hospital’s (KNH) Accident and Emergency Ward. She is waiting for an emergency surgery to remove a keloid from her abdomen.

Written on a white tape on her forehead, next to her name, is the word ‘Alone’, as she came to the facility unaccompanied and there is no one to assist her through the process.

Keloids are smooth, hard, benign scars or growths that form when scar tissue grows excessively. Achieng has various abdominal keloids but the largest has a blood clot. Owing to the excruciating pain, she rushed to KNH.

It is now slightly past midnight and the lean team on the night shift is overwhelmed, given that most patients walk into the facility without referral letters.

This is despite efforts to decongest the Level Six facility by rejecting walk-ins, who make it nearly impossible for staff to offer adequate services.

The doctors, however, cannot turn back patients like Achieng, and at half past midnight, surgeons, including a plastic surgeon who takes the lead, embark on an operation to open, drain blood, clean the area and close the wound in an aesthetically pleasing way.

Walking around the facility since 8:00pm on a Friday put this reporter at the centre of the busiest Accident And Emergency Department where the staff deal with cases of medical trauma and high drama all round the clock.

When the shift started at 5:30pm, they had to brace themselves for any eventuality given that it was end of the month and  a Friday evening. Trauma incidents top the list of cases they receive here; from accidents to stabbing and robbery victims who come with broken limbs. This night offers just that.

It is 8:55pm and the waiting bay at the Accident and Emergency (A&E) section has eight patients lying on stretchers waiting to be seen by a nurse at the triage while others are waiting get their lab results before the next course of action is taken. There are six doctors on this shift that ends at 7:30am and the number of patients walking in is not something they can control.

They do, however, have a colour-based system that ensures patients are handled according to the severity of their cases. This is done at the triage point of care, where the physician does an evaluation to help identify critically ill patients.

A patient whose file is marked red is considered an emergency case, those with yellow on their file are to be seen within 30 minutes, orange-coloured file holders need to be seen in 15 minutes and a patient with green is stable but has to be seen within the hour.

The system notwithstanding, people still come to the facility expecting to be seen within an hour or less but end up spending the night at the facility.

By 9:35pm, seven ambulances have arrived from different counties, with each patient looking worse than the next. Others, like two-and-a-half-year-old Angel Fridah from Kangemi came here with the help of their neighbours.

Her file is marked red, so she is immediately taken to the Resuscitation Room B (RRB), where doctors cut and peel off her clothes, which are stuck to her burnt body. Her mother, who sits by her bed as the doctors perform first aid on the little one, explains that she was preparing dinner when everything went wrong.

“I was boiling water to prepare dinner when she tripped over and knocked the sufuria,” says the mother of two, further explaining that her husband had to stay home to take care of the other child.

There are six beds here, three of which are occupied. The bed next to Fridah’s is occupied by a young man whose leg is broken and whose clothes, now lying on the floor, are bloodied, from what looks like a vicious attack.

He is surrounded by medics, who are trying to stabilise him before he undergoes a CT scan – which combines a series of X-ray images taken from different angles around the body and uses computer processing to create cross-sectional images of the bones, blood vessels and soft tissues inside the body. CT scan images provide more detailed information than ordinary X-rays do.

The wailing baby and the constant beeping of the machines being used to stabilise the man do not seem to bother the staff as each goes about their duties. Once he is in a stable condition, he is taken to the next block to have the scan done. This happens at 12:47am.

But within five minutes of being inside the machine, he is quickly removed, put in a stretcher and wheeled back to the emergency room. It turns out he became unconscious in the middle of the procedure.

Panting underneath their masks, the doctors are running; each holding the stretcher with one hand as they take him back to RRA to resuscitate him.

Once he is stabilised, he will be sent to the ICU or theatre, depending on the findings of the CT scan.

Unfortunately at this point, I cannot walk in to see what is going on but upon inquiring later, I find out that he got stable enough to go back to have the scan done before the doctors would recommend the next course of action.

Dr Wamutitu Maina, who is charge of this unit, explains that this is a common occurrence and their biggest challenge is having “unknown” patients such as the young man dropped at their doorstep.

“Seventy per cent of the patients we receive here are accident victims; with our biggest challenge being the patients who come with no family or identity cards,” he says.

It’s now 12:54am.

There are 15 women seated on a bench, heavy shawls barricading them from the cold as they try to catch some sleep and wait for their loved ones, who are at different points of care.

One mother is asleep as her young baby breastfeeds, clearly tired from what seems like a long night. There are two women, sisters-in-law, who have travelled from Taita-Taveta with their relative.

“We came here with my husband, who was attacked by a buffalo. The animal gored him in the groin area, which has affected his urinary tract. He is in need of an emergency operation,” says Elizabeth Wawuda.

She says that upon inquiring as to how long the husband will be here, the doctor said no less than three days, which means that the two sisters-in-law will sleep on the benches and wait outside on the grass for the entire time as they have nowhere else to go.

The story is the same for many of the patients’ relatives here, and the hospital, which does not have a place to accommodate them, cannot kick them out. The hospital staff only ask them to move from one side to the other at 3:20am to allow the cleaners to wash and sanitise the entire A&E unit.

While there is much going on in RRA, the situation is a little different in RRB, where three elderly women occupy the six-bed ward. The woman in one of the beds was brought in on a stretcher by her relatives at 12:17 am. The frail-looking woman, who seems to be gasping for air, can barely blink and despite the fact that she does not have a referral sheet, doctors rush to attend to her given her dire situation.

As they put her on oxygen, the doctor in the next room calls out for the next patient in line. There is no one left to see in ‘Room 5’, which is the obstetrics and gynaecology department of the A&E department, and he goes back to his desk.

Dr Clifford Oteko, the team leader of this shift, explains that this particular unit of the A&E deals with women who come in to see the doctor on matters related to reproductive health; mostly pregnant women.

“We see women who are 20 weeks pregnant and below because after 20 weeks you are automatically sent to the labour ward. There are also cases of botched abortions that are sent to ward 1D, which is in the next building,” he says.

Keep bodies

During my tour of the facility, I notice a long corridor that stretches to a two-door hallway, with the wards on the left side. I have never inquired what is on the right.

“That room is where we temporarily keep dead bodies before they are collected by the mortician from the hospital’s mortuary,” Dr Oteko explains.

I later learn that on this particular day, out of the 79 walk-in patents, a 77-year-old man died at 10:51am and woman at 5:40pm. Her body was picked up just an hour after my arrival at the facility. A man had picked the key from the nursing station, next to ‘Room 6’, which offers counselling for patients and staff.

The nurses’ station is also where calls come in from different county hospitals, such as the one from a hospital in Ngong Sub-County at 9:00pm. The nurse inquires if they have called Kajiado County Referral Hospital, which they have not, and advises them to do so before bringing the patients to KNH.

Her directions are informed by the referral protocol, which does not allow a patient to refer himself or herself or a hospital to bring in patients without going through the various facilities before reaching the national referral level.

In an ideal referral system, a patient has to first go to a Level Two health facility such as a dispensary that is run by a clinical officer. These hospitals offer outpatient services, including voluntary counselling and testing, pharmacy, laboratory and well-baby clinics.

If the patient does not get the treatment they require, they are referred to a Level Three facility. Level Three hospitals are small facilities run by at least one doctor, clinical officers and nurses offering services such as in-patient care, laboratory, dental, counselling and pharmacy.

They also provide primary care services but with additional support. They include health centres and maternity and well-baby nursing homes. Many are currently able to offer in-patient services, mostly for maternity care. These facilities mainly receive referrals from Level One and Two hospitals.

Level Four facilities are the first-level hospitals whose services complement the primary care level. Together with Level Five facilities, these form the county referral hospitals. A majority of the referrals to this level are from Level Two.

Hospitals at this level offer in- and out-patient services and have large laboratories that provide diagnostic services that would not be available at the primary care facilities. In emergency cases, referrals may also come from lower-level hospitals.

Level Five is the secondary referral level and offers a broad spectrum of specialised curative services. At this level, facilities are able to offer advanced services and expertise both for curative and diagnostic purposes.

If all else fails, a patient can be referred to a Level Six hospital. This category comprises the tertiary-level hospitals whose services are highly specialised. These are the ultimate referral points, mainly national teaching referral hospitals.

The entire cascade and network of referrals in the Kenyan health system goes up to this level, where very specialised skills, expertise and services are offered and linkages with local and international universities, facilities, and staff are forged and maintained.

After less than an hour, the hospital in Ngong calls to have the patient referred to KNH, then the Kajiado Sub-county Referral Hospital calls saying they do not have a specialist for neurotrauma since the patient had an injury to his head.

At 1:02am, there are 13 ambulances that have brought in patients from various counties, among them the one from Kajiado County, who is taken to the wards to be prepared for surgery.

There are also ambulances from Makueni, Nairobi Metropolitan Services and even Kenyatta University Teaching, Referral & Research Hospital, which is a Level Six facility like KNH. Most of the ambulances, however, are privately owned and therefore do not call the facility prior to bringing in patients, who are mostly from various accident scenes within the city.

The ambulance from Makueni County is carrying a 10-year-old boy who has intestinal obstruction, which Dr Wamutitu explains as a blockage that keeps food or liquid from passing through the small intestines or large intestines (colon). The vehicle arrives at the facility at 12:24 am.
Causes of intestinal obstruction may include fibrous bands of tissue (adhesions) in the abdomen that form after surgery; hernias; colon cancer; certain medications; or strictures from an inflamed intestine caused by certain conditions such as Crohn’s disease or diverticulitis.

“Without treatment, the blocked parts of the intestine may die, leading to serious problems. However, with prompt medical care, intestinal obstruction can be successfully treated,” he says.

That and the fact that Makueni County does not have a paediatric surgeon is the reason the boy, who is accompanied by his mother, is taken in and rushed to the A&E, where he is assessed before surgery.

Things slow down around 4:00am when the cleaners finish their work. The hospital is quiet, except for a few snores from some of the women sleeping on the benches.

At 5:34am, the family of a businessperson from Bisil, Kajiado County, who had a head injury from a road accident, finally gets out of the unit and proceeds to the wards after a night at the hospital.

The nurses at the station do their report at the end of the night. One had been in charge of administrative issues and the other one was coordinating the referrals. On this particular shift, there were 25 admissions to various units such as surgical trauma and orthopaedics.


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