Through an open-air hallway sheltered by a slanted aluminum awning, we briskly stride past the male medical ward, radiology department, and billing services until we reach the strikingly white door of the intensive care unit (ICU). A whisper of warm breeze sneaks into the vestibule with us as the door swings shut, and we quickly slip into one-size splashproof shoes before entering the two-bed ICU. Here, the lone pump-based infusion set at this hospital looms over a patient’s bed; he is ventilated and on pressors.

In the adjacent (and only other) bed lies our patient, belly ballooning in and out with her staccato breaths – this deep, rapid cadence of inhale and exhale is the hallmark of Kussmaul respirations. This is her third recurrence of diabetic ketoacidosis (DKA) during this admission. The medicine intern, already at bedside, has her gaze locked on the standard, plastic intravenous infusion set, counting the rate at which drops are falling into the infusion chamber with laser precision. Manually adjusting the drops per minute is how the rate of insulin infusion will be titrated to manage this patient’s DKA, since the singular pump-based infusion set (which allows for automatic and precise rate adjustment) is already in commission for the other patient’s blood pressure support.

DKA is a common reason for admission at Naivasha Sub-County Referral Hospital (NSCRH), where my home institution, the University of Washington (UW), has a longstanding partnership. My month-long global health rotation at NSCRH earlier this year marked the first time a fellow-in-training visited for a clinical rotation. There are no endocrinologists at NSCRH, so the overarching objectives of this rotation were to (1) share my expertise through bedside teaching, didactics, and quality improvement (QI) and (2) gain experiential insight into global health endocrinology and endocrine care delivery in a resource-constrained context.

Prior to my rotation, I met with the UW global health chief resident and clinical leadership at NSCRH to discuss how I could be most helpful during my time on-site. Inpatient DKA management was identified as a key area of focus, especially in light of a DKA-related mortality a few months prior. To address this gap, I began by conducting a needs assessment with care providers to understand their concerns around DKA care delivery at the start of my rotation. I then developed a curriculum to improve trainees’ comfort with DKA diagnosis and management. This curriculum included both interactive didactic lectures to build a strong foundation on DKA pathophysiology as well as a practical case-based simulation to model clinical application. I also worked with key stakeholders in designing a QI project to implement and assess changes to the DKA algorithm. As an endocrine fellow in Naivasha, I was uniquely positioned to devote time, energy, and resources to this specific need, which helped to build momentum and excitement around improving DKA outcomes.

At the same time, my extensive clinical expertise in this area did not automatically translate to preparation for the nuances of practical application in this care setting. As I watched the intern counting out the drops per minute to set up that IV insulin infusion in the ICU, I was uncomfortably aware that without the familiar resources of an electronic medical record, an automated infusion pump, and a nurse-driven insulin treatment algorithm, I could not easily track a patient’s progress along the DKA care pathway. In this way, the collaboration with staff and providers at all levels of training served as the foundation for the success of our efforts.

Through the needs assessment and direct observation, challenges in the transition from intravenous to subcutaneous insulin therapy during DKA management emerged as an integral contributor to rates of DKA relapse (that is, returning to a state of ketoacidosis after initial resolution). Our updates to the algorithm included more robust guidance around management in this critical period, and the educational interventions focused on the pharmacologic underpinnings to help trainees understand the rationale for the changes. Initially, the impact of these changes showed a dramatic decrease in the rates of DKA relapse - in fact, the week following our case-based simulation teaching with the interns, all four patients admitted with DKA did not experience relapse of ketoacidosis. However, months after the end of my rotation, the data and anecdotal observation suggest that this improvement has waned somewhat. We are actively working to address the challenges that have been identified, and I am grateful to be able to continue my involvement, now remotely, in the ongoing efforts around quality improvement related to DKA outcomes in Naivasha.

Thanks to the support of the AACE Lewis E. Braverman Endocrinology Fellow-In-Training Travel Grant, I was able to dedicate a month of my training to this deeply enriching experience. It has helped to affirm my interest in building global health into my career and reimagine how I can add value in a global health partnership with my clinical expertise as an endocrinologist. I would also like to express my gratitude to the leadership at NSCRH, including Dr. Patrick Asaava, Dr. David Muigai, and Dr. Douglas Bosibori, my faculty mentors at the University of Washington, including Dr. Stephanie Page and Dr. Tracy Tylee, the UW global health chief resident, Dr. Monica Soni, without whom the outcomes of this rotation would not have been possible, and all the members of the NSCRH community who were so warm in welcoming me to Naivasha.

The Dr. Lewis E Braverman Endocrine Fellow in Training Educational Grant is a one-of-a-kind grant program offered to fellows in the United States to take part in unique clinical experiences worldwide.