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Sunday, October 19, 2014

Ebola, Incarnation, and Cost

Thanks for reading the ebola post, and thinking about it.  We are given the blessing of being part of the way God blesses the world.  I hear a lot of fear, and I want to hear that with compassion.  But being a blessing is a costly pursuit.  Just ask Jesus.  He said "take up your cross".  So if American soldiers and doctors and epidemiologists and pilots all do that, Amen.  A few may get sick.  Most won't, and in the process will have the opportunity to be part of a story of redemption that is thousands of years in the telling.  Some of the comments on the post are supportive, some are hostile.  We have left them all up to respect the diversity of opinion.  One sticks in my mind, and I think will become my new description of the incarnation:  "skinny-dipping in ebola juice".  That was meant to chastise us (even though we're currently thousands of miles away in Kenya).  But it is a vivid image of Jesus, safe in eternity, entering this world of muck and danger, for us.  

Beautiful Dust

Walking into brokeness means a lot of brain tumors.  I didn't think I could handle another brain-dead child on a ventilator, another entry to the ICU to find a new patient, to examine, to slowly realize the very peaceful looking little body with its stillness and steady heartbeat belies the truth inside his skull, which looks like this:

The agonizing conversation, the weeping mother whose lament is translated for me "I would gladly cut off both my arms here and here to save my child".  The bewildered father, holding his wife, sniffing his tears.  The stoic aunt watching with me as we remove the tubes and his heart beat slows to a dwindle, then nothing.  He is gone.  The prayers.  The ache.  These last ten days have held four similar scenarios for me, and I am losing my resilience.

They have also held a series of sermons and worship at RVA.  Once a year the school has an invited outside speaker, and nightly meetings.  This year we heard from Eugene Cho, who pastors a church in Seattle and started an organization for justice called One Day's Wages.  This has been a draught of grace, an infusion of the Gospel, a picture of God's loving purposes in our messy lives and His invitation to step into the world alongside His work.  Eugene is a TCK, born in Korea and raised in America, with the kind of life experience and pain and redemption that speaks to the kids here.  And to me.

One of the songs I have loved in the worship time has a line "You make beautiful things out of the dust".  Last night, Eugene talked again about how God is with us in the low times when we can't see His purpose.  About how He invites us to respond.  He asked kids to raise their hands as we sang.  I was on call, and sitting in a back corner.  A girl in the row ahead raised her hand, tentatively.  I watched her friend on one side go forward to pray with a teacher, and her friend on the other side jump up to hug the first friend.  But she sat quietly in her chair.  As we ended, I put my arm around her shoulder, and asked her name so I could pray for her.  She said she didn't know any of the teachers up front well, and wasn't comfortable going ahead.  I promised to pray, respecting the private holiness of her moment.  But my phone was buzzing.

Scott had decided to take a 31-weeks-pregnant mom into the operating theatre.  Her life was in danger from severe pre-eccplampsia.  They were about to pull out this very premature baby, and I ran down the hill in the rain to be there.  The theatre lights at night, the bustle, the scramble to get our equipment prepared, and then the little guy was out, limp, whimpering.  But with a bit of vigorous drying he was crying.  A beautiful little boy, tiny and complete.  Here he is 30 minutes later, having pushed his oxygen up onto his forehead.  He didn't really need it.
Beautiful things, out of dust.  A shy young woman, making a spiritual commitment.  A tiny baby, all 1380 grams of him (2+ pounds), kicking and complete.  New life, of the soul and the body.  

Redemption comes, slowly, in unlikely places.  A shy student and a preterm baby.  And redemption comes with cost.  Late nights and missed events.  Weary bodies.  But it comes.  Beautiful things formed out of dust.  Broken places healed.

Friday, October 17, 2014

Ebola

We have been avoiding the topic, honestly, because it is a raw one for us.  In 2007 we lived through an ebola epidemic.  In the remote area of Uganda where we worked, along the Congo border, ebola crossed over from the animal reservoir in the Ituri forest and began infecting humans.  We were both exposed before we knew that the disease was ebola.  Our best Ugandan friend and colleague Dr. Jonah Kule died, and the only other doctor besides us in the district of over 200,000 people became infected but recovered.  When the disease was confirmed, we sent our kids away to stay with other missionaries until we completed a 21 day disease-free incubation.  We decided at one point that only Scott would see patients and I would not, to minimize the risk of both parents going down.  For months we lived with the lingering cloud of doubt, the on-edge expectation of potentially deadly touches in our medical care, the grief of losing our friend.

So we have been following the news of this epidemic very closely, communicating with some of the organizations involved, praying.  It would not be an exaggeration to say that it has dominated much of our mental and emotional energy for the last month.

Now that 2 people have been infected in America, and there is mass hysteria, perhaps a few words are in order, even though we are actually no closer to the epicenter here than most people reading from America are (we are several thousand miles away).

This is a West African epidemic.  It is sad and regrettable that one of the hundreds and hundreds of travelers who come to the USA from this area happened to have been exposed in an act of kindness, and got sick.  And that two nurses are now infected.  However this in NO WAY makes the American experience in any way comparable to Liberia, Guinea, or Sierra Leone.  That is two transmissions out of hundreds of millions of people.  The risk in America is extremely low.   Americans have gloves and masks and running water and bleach and hospitals and suits and disposable everything and money and transportation and doctors and nurses and janitors and experts.  Americans have panic, and demands.  In American culture, no-risk of a disease is considered to be a birthright; yet people routinely drive too fast, eat and drink too much, play with guns.  Or fly in airplanes or rock climb or do a thousand other things more likely to kill them than ebola.  The point is that in spite of headlines about school closings and plane cleanings and it's all Obama's fault somehow, the virus will be contained in America.  West Africa is another story.

Ebola is a tragic and frightening disease, because it is transmitted by the most basic human acts of community.  Wiping tears, carrying a child, cleaning up a mess, hugging.  And it seeks out those most caring.  I think it frightens by being mythically diabolical, killing the very people who are most bravely fighting against it.  The PPE's turn people into spacemen, aliens.  The origin is in Africa and that is always suspect.  So it is hard to separate the emotional layers from the facts. (This graphic on health care workers is from a Forbes article: 232 deaths out of 404 infections).

Ebola does not have to have a 90% mortality.  One of the surprises of this epidemic is that a good number of the people who by nationality or connection got airlifted out and received intensive excellent care actually survived.  The official stats are running at just over 50% mortality, though the treatment centers see more like a 70% fraction of death.  Our own epidemic was less than 50%.  I thought that was because our virus was different.  But maybe it was just good care (smaller numerator) and compulsive case finding (bigger denominator).  Medical care makes a difference.  The sick should not be written off as hopeless, and locked in isolation to die.

The leaders in compassionate response are the African doctors and nurses and community health mobilizers and ambulance drivers and taxi-owners and parents and friends.  But they were too few six months ago, and they are many fewer now.

I am glad that the American military is responding.  I know it is not politically savvy to be in favor of marital law.  But this epidemic needs an infusion of organization, of money, of can-do, of discipline. In Bundibugyo, MSF came in with tents and supplies.  Our airstrip became the staging area for sending samples out and people in.  Our district leader (RDC in Ugandan parlance) was ex-military, and he kept everyone working together.  Every night we had a close-of-day meeting and coordination time.  It was local, and we were far from the rest of the world, and it worked.  In the current epidemic, decades of civil war, resource pillaging, injustice, poverty, distrust, corruption, etc. have weakened not only the health infrastructure but the political organizing ability to gain momentum.  So if that requires a temporary military infusion, so be it.  Allowing people to continue to suffer insecurity and chaos is not helping anyone.  If we say we care about justice, then it is legitimate to respond to this need JUST BECAUSE PEOPLE ARE SUFFERING and not because we're trying to protect the plague from coming to America.

There are two things that will stop the epidemic:
1.  Treat the sick, humanely, safely, respectfully, compassionately, expertly.     For this we need those treatment centers built, now.  And staffed. The American military is one of the best organizations on earth poised to mobilize buildings and equipment and expertise.  So please don't object.
2.  Trace and monitor the contacts, isolating anyone with symptoms the very hour they become sick.  In Bundibugyo we had massive community mobilization.  There was nowhere to go really.  It was horrible to never touch anyone, to sit apart, to be so careful.  But when we were in our 21-day riskiest period, we did that.  It is possible to stop transmission if this is carefully followed.  Personal liberties have to be curtailed for a while.  Asymptotic people are not a danger to anyone else, but it makes sense to lay low in case this is the day symptoms would start.

And neither of those two things are happening very fast.  The countries involved have resources similar to Bundibugyo, meaning not many.  The few responding organizations are overwhelmed, and don't even have the administrative capacity to do much more.  So . . .
1.  Be informed.  Here is Paul Farmer's analysis.  The New York Times and the Washington Post have sane and thoughtful articles.
2.  Support SIM, MSF, IMC, Americares, Samaritan's Purse.  Support our troops.
3.  Pray.

Jesus would be more concerned about helping the sick in Liberia than castigating the CDC in America.  He would be touching the contaminated, and comforting the mourners, and bringing hope.  Let us do the same.




Tired of Death, Poured out, and yet glimpses of hope

I guess that title could be the tag line of our life.
This week I am mostly tired of death.
Two deaths, two days.  And sometimes I forget how draining it is.  The first was a blue baby.  Her name was the same as mine, which shouldn't be jolting but sometimes is.  She was born to a very culturally intact rural family, at home amongst the cattle, no immunizations or medical contact until she began to fail near the one-month-mark.  At Kijabe she presented with what was thought to be a pneumonia, then her spinal tap was abnormal so meningitis was suspected.  That level of infection tipped her barely-balanced heart into dysfunction so that she turned very blue.  Our best-guess non-expert echo was that the veins from her lungs emptied into the wrong chamber.  
I spent the day with my colleagues trying to stabilize her in the ICU, intubated, with drips and monitors and full-court-effort.  And on the phone to see if we could transfer her to the main government hospital where a cardiologist could give a definitive diagnosis, to know if there was any hope.  That night I was at her cot from 1 to 3 am, and back at 6-something, and again at nearly 8am.  At which point she was dying, and though I hated to give up, I had to make the call that the CPR and every possible medicine was not bringing her back.  The worst part is telling the mom.  The stoic group of men who had listened to the poor prognosis and were resisting the attempts to transfer the day before were now gone.  It was just me, the nurse, and the mom, whose clothes gave off the earthy smell of a kraal, whose face was far from stoic.  She wept, quietly.  She didn't want to touch the baby.  I held back tears, filled out the death form, prayed with her, held her hand.  

The next day it was a 3 year old with a brain tumor, who was a week out from surgery to remove what could be removed.  But the tumor had infiltrated his brain stem, the crux of all essential life processes.  Since surgery he had not really woken up fully.  He wasn't talking or moving, though he seemed to sense pain.  We had spent days in ICU regulating him, and now he was in our step-down HDU.  I had talked to the neurosurgeons about his case which seemed pretty hopeless, but they still thought if he revived he might be able to get radiotherapy, and perhaps have a chance of survival.  Irradiation to a 3 year old's brain stem is no small matter, even if there were more than two machines in the entire country, even if they family could afford it.  Yesterday afternoon I heard he was "complicating" from a CO intern who was running to the lab for blood.  So I ran to his bed and found him without a pulse or breath.  The nursing team sprang to action and with a colleague we did CPR and bagging breaths and a line and medications.  I appointed a timekeeper and said we would try for so many rounds and then accept his death if he did not respond.  Nothing.  

Again, the worst is going to find the relatives.  In this case an auntie who had spent her own savings to rescue this child.  His family was unable to care for him, his mom confined with a newborn a few days before he came.  She was determined to do her all, so she brought him all the way from Mombasa.  I found her with red eyes and streaming tears, being comforted by the chaplain.  Is it over?, she asked. Yes, I said, sitting down to put my arm around her.  Thank you God, she said with hands raised. Not the usual response.  She went on to explain that she had seen how much her nephew was suffering.  She knew that a full week out from surgery he should have been recovering, but wasn't.  And she had prayed that day, God, please just take him if he can't recover, don't let him go on suffering like this.  Wow.  It strengthens my faith to see the Spirit preparing someone like that. She had a sense of what to pray, and she met Jesus in that process.  If we truly believe in Heaven and healing and hope, then this boy's death becomes part of a larger story.  Yes we are sad for his family, yes we believe in giving our best care and fighting against cancer and infection and every other evil.  But when we reach the limits of the battle, and we lose, we lean on the assurance that the ultimate outcome is still Goodness and Love.

Walking with families through the valley of the shadow, the very essence, of death is a holy privilege.  I believe in compassion, information, the assurance of doing everything humanly possible.  I believe in praying and grieving.  In creating a safe space, in letting go, in closure.  I think we do a pretty good job of this as a hospital.  But it has a high cost.  Isaiah 58:10--if you pour out your soul for the hungry.  This is a job with a lot of soul-pouring-out.

And not always a lot of space for recovery and pouring-back-in.  But today as I reflect, I am thankful for quite a few other stories.
Precious, against all odds, is actually starting to breast feed. She cries and moves and looks at her mom.  Her little brain has a long way to go, but she is miraculously alive and recovering.  And her mom has been so touched by prayers for her daughter.
Little L, who was paralyzed in the ICU a couple weeks ago, is sitting and smiling.  He can only barley lift his arm and wiggle fingers and toes, but he is progressively strengthening.  He should go home today.

Grace, the little girl who wants to go to school, I found with a coloring and sticker book yesterday, courtesy of visitors.  She flashed me a huge smile.

A boy "I" with diffusely swollen joints, severe pain, a raging fever, a month of almost continual suffering . . . was alert, talking, and without fever for the first time after getting the right treatment.  Hooray.


One of our most connected, visionary, wise, committed docs (Mark Newton!), came back from his frequent trips to America, this time with promised equipment courtesy of General Electric.  This is a new GE ventilator and monitor being installed in ICU yesterday.  We need at least two more ventilators for our new Paediatric HDU/ICU area when the new BKKH wing opens in 2015, and nine monitors.  As our care improves, the sickest patients find their way here, and we need more space and equipment to care for them.

This is our very own Dr. Nthumba, who was a surgical trainee back when we came here to have babies, and now is the head of Medical Education, one of our most senior doctors, and a leader in Africa.  He is featured in a WHO video about how to "first do no harm" and prevent poor outcomes in our patients, focusing on using teamwork and communication and checklists and attitude to reduce surgical site infections.  We had a meeting about this today.  I don't do surgery, but the principles of reviewing problems, addressing systems rather than assigning individual blame, learning from mistakes, building collaborative relationships, welcoming team work and input . . . are excellent and the kind of atmosphere I want to work in.  I love our Paeds team and believe we are solidly moving in this direction.  

Then there are smiling teenage faces that lift my spirits.

This past weekend was a midterm holiday so we ended up with first one, then two, then three, then four senior boys in the house.  On the left Jack and John Amos are working on college applications, the comfortable way.  Nothing like a dog and a hammock to improve your writing.  I spent the weekend editing essays as fast as they flowed out.  Which is a good way to re-appreciate how amazing these kids are, resilient, funny, wise, true.   To the right are a bunch of kids who came for lunch yesterday to celebrate Rich's 18th birthday.  We made pizza in spite of rain, and celebrated this kid who has been a loyal and polite and godly friend to Jack since the day we moved here.  Most of the guys in that photo have played sports together on multiple teams nearly every season for five years.  They are also in our Sunday School.  Plus Acacia and Adrienne, who bring class and some decent pizza-making skills to the whole process.  Sadly a group of RVA students staying with a missionary in Nairobi last weekend were robbed at gunpoint as they entered her apartment.  One of the boys came back and stayed with us afterwards as they debriefed and recovered (not pictured).  Please pray that his new computer which had all his college application work, including his musical portfolio, would be miraculously found and returned!   And that he and the other kids would find comfort in Jesus after a very traumatic experience.  RVA ranked as the #2 high school in Africa in a newly published report, which is a continent of over a billion people and many good schools, particularly the prep-schools in South African and the International Academies in most capital cities.  So that's another thanks, for the teachers and students and dorm parents and counselors and cleaners and administrators and drivers and coaches and community that make this place possible.  

It is Spiritual Emphasis Week, and we've been grateful to hear Gospel-centered from-the-heart solid truth from Eugene Cho and a great worship team the last two nights:

Thanks would be incomplete without mentioning our supportive Serge team here.  Karen, Ann, and Bethany have prayed and cooked and listened and walked.  Here we are on a rare hike, to Big Fig:

And even more thanks to our extended team in the USA, especially the Crumleys, Bolthouses, Harteminks, and others who have reached out to our college/grad school kids.  Julia was able to fly out and visit Caleb for an Officer's Christian Fellowship retreat; Luke had a great Fall break with friends followed by a Christian medical fellowship retreat.  We miss those three so much, it is a draught of fresh water to see them connect with rest and with families who love them and with each other.


Let me close with a last thanks to Carol Logan, who left us a bag of mint M and M's as she departed.  Wow.  It's the small things.  Pretty awesome.

We are tired and poured out, but not defeated.  We have hope, and green minty chocolate, and each other, and you.  Thanks.







Wednesday, October 08, 2014

Kijabe paediatrics

This is what life is like as a Paediatrician in a busy referral hospital in East Africa.




Early mornings, because Jack is taking a class on-line, and it meets on a CA schedule.  Plus I've finally figured out that it is impossible to carve out time for prayer and exercise unless it is dawn-ish.  Make breakfast, read aloud devotions, check email, get ready. A frustratingly concrete new hospital policy separates patient and staff entrances, so we have to walk to the opposite side to enter and exit, doubling our few-minute commute.  Sounds trivial.  It isn't, because we are always pushing on a nearly-disappearing margin.  

Then the race begins.  Check in on ICU patients, touch base with the excellent clinical officer working with me there.  Pour over labs, check ventilator settings, examine x-rays.  Try to get to the paeds floor, the nursery, the casualty, and the MCH clinic all before meeting with the overnight team for morning report at 8:30.  Evaluate any admissions still waiting for beds.  Teach trainees as we review cases.  Then rounds, with the brilliant adult ICU doctors, in which I pretend to merely listen while I'm actually learning just as much as the interns.  Bop down to pathology to find out a patients's spinal mass is a very malignant astrocytoma.  Check in the lab to see if another patient's stool sample for polio ever got sent.  Meet the maternity in-charge to hand-over a donated syringe pump for babies.  Generate a list of pending admissions and talk to the nurses about discharges and bed openings.  Get called to private clinic to see a more well-to-do family referred from Nairobi with a shopping bag full of reports on a teen with chronic pain issues, which takes an hour of concentrated attention to be sure that there is no dire illness, rather the harder issues of life and relationship.  Get paged out of that for a code to find another teen who is paralyzed and may have a blood clot and needs immediate care.  Try to make a reasonable plan for her while seeing the minutes tick by to get up to RVA clinic, late as usual.  Meet with some parents and kids, always a great thing, good nurses, brave teens, chronic illnesses, low resources, insights, encouragements.  Tough problems, few experts.  Feeling out of my depth.  But enjoying the people and the challenges.  Back to our hospital MCH clinic to look at a rash that has puzzled the clinicians.  Start call, preterm twins.  Pull together dinner, or more likely, help Scott do so since he's already started.  Scour news reports about ebola, talk about it, feel the reality and loss and helplessness.  Remember friends.
  
That's the mostly good parts of yesterday and today mashed together.  But there were harder parts too. Two babies in one day admitted to ICU brain dead.  Two times to go through the whole heart-wrenching process of explaining the hopeless situation, of answering questions, of examining and re-examining to be sure the brain is gone, pouring over the file, calling or finding the midwife to hear about the delivery, the anesthetist to hear about the surgery.  Sometimes things go wrong.  Very wrong.  Baby J was born unexpectedly stressed, with meconium and a low heart rate and a limp body.  Baby F was a thriving two-month-old who stopped breathing a couple hours after an operation to repair his cleft lip.   Both needed CPR.  Both had a beating heart but not much else when I received them.  Both, one could argue, should never have been on life-support, but in both cases the process was good.  I could meet families, call in chaplains, pray, explain, advise.  Both moms held their babies as they died, with support and tears.  And truth.  And prayer, lots.

By this afternoon, post-call, 11 kids waiting for beds (admissions from casualty and clinic and surgery) but no beds at all amongst the 50-some for paeds.  Oh, there are 10 discharged patients held "prisoner" for unpaid bills.  Hard.  Two deaths, hard.  Tiredness, hard.  Sick colleagues, interns pulled out for government registration exercises, hard.  Sitting down as a team to debate care for super-complicated patients with rare congenital anomalies and serious fungal infections, hard.  Talking to a colleague about the government, public health, the big picture, priorities, realities, hard.

I love this job, and yet some hours I want to quit.  When sorting through dozens of texts and emails and complaints and absences and malfunctions, when work piles up and solutions are elusive.  When I keep adding meetings, budgets, research, projects to the to-do but not-likely-to-get-done list.  Then a little girl on the Paeds ward I'm helping consult on takes my hand, and says in Swahili even I can understand, doctor, I want to go to school.  She's 6, paralyzed by spinal bifida, malnourished, being cared for along with 11 cousins by a barely-functional grandmother.  Her lifeless lower body has sores so bad the bones of her legs are poking through.  She needs amputations.  But even so, what she wants is a book.  To read.

So I keep on keeping on.  I call the amazing chaplain Mercy to see little Grace, and she leads her to Jesus.  And tells me she's working on helping her to get to Joytown, a school for children with disabilities like hers.

This is Paediatrics in Kijabe.

Monday, October 06, 2014

Cautiously Hopeful



Look who opened her eyes, and decided to breathe without the ventilator.  This Precious girl is still far from OK.  But a week ago I would not have thought we'd be here.  Survival itself is an unlikely gift.  Survival with anything close to a normal brain would be a real miracle.  Please keep praying for this family.

Sunday, October 05, 2014

On becoming a patient...


Fridays are busy because the bulk of our OB-GYN Department spends the day in clinic seeing women with all sorts of sad and complicated problems – cancer, infertility, chronic pain and the like.  Which leaves me juggling the chaos in Labor & Delivery.  Not alone mind you – there’s a strong team of midwives and various trainees – but I’m the only “Consultant” around to assist in decision-making.

Near the end of our ward rounds, after seeing about 30 inpatients, I’m informed of a patient who just rolled in the door with fetal distress.  “Thick meconium” is the presenting complication– a reliable sign that the baby is “not OK.” By the time I’m informed, the patient is already in the Operating Theatre being prepped for an emergency Cesarean.

I arrive and the Anesthesia Team is in Rapid Mode – drawing up drugs of various sorts into small syringes, putting in an extra IV line, a Foley catheter.  Confidently and efficiently.  There’s no panic here.  We swiftly complete our pre-op Time Out review.  Within 15 minutes, I am making the incision in the skin.  Within 2 minutes, I’m extracting a baby covered in mustard-like slime – but the baby cries weakly.  Ten minutes later the Pediatric Team comes back with a clean and restful baby who has been rescued from the brink.

We’ve just received a new set of Medical Officer Interns this week.  These two young Kenyan doctors are halfway through their one year internship, but have minimal experience in obstetrics.  It’s our task to transform these two into doctors who can confidently and competently manage women through their pregnancies and deliveries – including the skill of performing Cesarean sections independently – by the end of their three month block with us.  So, I invite my assistant to switch places with me so I can assist her in finishing the closure on this Cesarean.

Closing the uterus is probably the most stressful stage of a Cesarean.  You try to work quickly in a fountainous pool of bright red blood.  The wound edges continue to bleed briskly until those edges are tightly sutured together.  I dab with large absorbent gauze pads, suction with a weak catheter, and instruct where and what to do.  Calmly, but firmly.  I reach with the gauze sponge… she reaches with her needle holder…gotcha.    The large suture needle catches my left index finger.  Ouch.  The surgical nurse sees it.  “Go, doctor.”  I walk out through the heavy swinging double doors, snap off my double layer of gloves and see the drop of blood oozing from my finger.  Within ten seconds, I’m scrubbing with liquid soap, running water, and even splashing some alcohol rub on there for good measure.  I see a puncture.  Bummer.

The HIV prevalence in Kenya, is officially somewhere around 6%.  That’s more than 1 million women in Kenya.  Our hospital’s immediate catchment is probably a lower risk area, but we get a lot of women from Nairobi which is probably a higher risk area.  Officially, the number of HIV+ women we deliver at Kijabe Hospital is relatively few – less than ten per month.  But the risk is real. 

So, I proceed to the ICU, which is the official keeper of the Post-Exposure Prophylaxis (PEP) Protocol and drugs.  It takes about 30 minutes to find the right people, but we do eventually find the notebook with the forms (to be completed in duplicate) and the pills.  Three monster pills – antiretroviral drugs - to be swallowed emergently until testing of the patient can be completed.  I choke them down.  Later we will have a more thoughtful and deliberate discussion and decision around the potential need to continue the drugs for a full 28 days.

So, I head back to the Theatre.  My intern is still completing the case now with one of our docs who left the clinic to come and assist.  I ask for blood to from the patient to be sent for HIV testing and it has already been done.  Now I become the patient.

In the AIDSRelief Testing Center, I get my blood drawn and am tested for HIV.  They know the drill.  They are sympathetic and professional.  My test is done in 5 minutes.  Negative.  Yay.

I now head for Medical Records to retrieve my Kijabe Hospital medical record.  “We can’t find it doctor – that is a very old file number.   Perhaps it was archived. (read: discarded).”  No problem – I’m healthy and have no significant history.  They issue a new one page Outpatient File and I head for AIDSRelief Clinic.  I am now amongst a group I have worked with for many years – HIV+ women – and I am in their shoes. 

The Clinic is spiff.  Brand new, spacious, bright, and out of sight from the rest of the hospital.   The patients seem comfortable sitting together and talking.  I am not.  I’m ushered into an examining room where a Clinical Officer (like a physician assistant) sits in the clinician’s chair with my file and I sit in the patient’s chair.  He reviews the history and writes a prescription for the 28 days of antiretrovirals.  It seems that even if the patient tests HIV-negative, there is always a lingering doubt about whether the patient could be in the “window period”  - infected in the past 6-12 weeks, but not yet testing positive.  We don’t have the HIV-RNA antigen test to exclude that possibility.  So, I receive two big bottles of pills and leave.

By 4:30pm, five hours after my injury I receive the news that the patient is HIV-negative.  Phew.  But that window period.  I consult with a lot of people – two of our Internal Medicine/Critical Care Consultants, our Senior Midwife, Head of Lab, our Hospital Chaplain…and Jennifer.  We decide to interview the patient gently – no waterboarding here – we just want the truth.  Have you had sex with anyone in the past three months?  Turns out she’s not married, she’s a student.  She insists she has not.  So, should we believe her?  Culturally, do women in Kenya have sex in the last three months of pregnancy?   Most direct answer I could get was … maybe.

I looked at the Adverse Reactions for the antiretrovirals I’ve been prescribed: Lamivudine, Tenofovir, and Lopinavir/Ritonavir.  The list of reactions can make your hair stand on end: pancreatitis, hepatic failure, vasculitis, nephritis, hypertension, heart attack…etc. 

My final read…

- I was stuck by a solid needle (a suture needle), not a hollow needle (syringe needle).  The risk is known to be much lower for this type of exposure.

- the patient tested HIV-negative.  While there is the theoretical risk that the patient could be in the “infected, but testing-negative window”, I am inclined to believe her statement that she has not been having sex with anyone in her final trimester of pregnancy. 

- I did take the “stat” dose of drugs which should have given me some protection.

So, I won’t be taking 28 days of those drugs. 
By the way, that first dose was pretty miserable.  The headache and nausea were considerable.  Which brings me to a final reflection…

The doctor becomes patient.  Certainly there were a variety of emotions.  Anger.  Angry with my trainee; with the system that puts me across the table with an inexperienced surgeon in a stressful situation.  Fear. Of the uncertainty of a potentially-life altering fatal, stigmatizing infection.  I navigated a complicated system of diagnostic testing and treatment. I struggled to judge the test’s reliability.  I received a bowl full of blue and brown double-edged pills with the power to prevent infection – and the toxicity to burn up my liver.  But there was also Gratitude.  Through it all, though, the Kijabe Hospital staff was compassionate and kind.  Of course, I’m aware I got lots of preferential treatment because I wore a long white coat with surgical scrubs underneath.


The enduring memory, however,  of this stressful day continues to be rubbing shoulders in the lab and the clinic with patients who similarly struggle…with much less education and preferential treatment.  To understand, to make decisions, and to hope.  My experience - I pray - will spill over into my rounds on Monday morning – for the good of my patients and God’s glory.

18 and Ache-ing



Julia's 18th Birthday, a moment for milestone thankfulness and wistfulness.  Mostly thankfulness, because she is a jewel:  precious, beautiful, shining, tough.  She has plunged into her first year of American school since preschool with courage and openness, making friends and enjoying classes and braving bike transport and the newness of just about every aspect of her life.  She is practical and prayerful and loyal and true.  We love her so much.
And thankful for our friends the Harteminks (and the Barts who connected us way back when) who invited her for a birthday dinner and cake.  And Grammy who could not come but treated cousin Emma and Julia to a dinner out together the night before in absentia.  And friends who hang out late at night in the dorm and celebrated her, and a thousand other things.












But we are also wistful, because we don't get to celebrate this milestone of transition to adulthood in person.  Because it is the beginning of the rest of life, when birthdays are spent mostly apart.  When we feel deeply the chasm of the continents, the time zone gap, the challenge of knowing our growing adult kids.


 Yesterday, on her actual Birthday, as I went to early morning rounds, I felt acutely the responsibility of someone else's daughter.  Precious came to us last Monday morning, as I answered a page in the early morning to come quickly to the casualty (emergency).  Three months old, she'd had a viral-sounding cough and cold that progressed to severe gastroenteritis and then seizures.  She was convulsing and barely breathing.  Her initial pH in the blood was 6.7, which is very very bad, not many people come back from that.  With our casualty doc I intubated her and we started repleting fluids in her shocky, dehydrated body.  I was bagging breaths with one hand and holding my phone with the other making desperate calls to rearrange patients and space and call in extra nursing help to allow us to admit her to the ICU.  Now six days later she was still alive, moving a little, slightly improved, but still comatose on the ventilator.  That first morning as I rushed around casualty, I paused to explain things to her mother.  Who stood there at the end of the gurney, tears flowing.  I don't usually hug moms, but this one needed one.  I tried to be soberly realistic.  Her daughter was almost dead, and we weren't sure we could pull her back.  But also hopeful, that God brought her here in time, that we would do everything in our power.  And my own heart went into this struggle as we prayed together.  Love costs vulnerability.  I want Precious to live.  I don't claim to care as much for my patient, someone else's daughter, as my own.  But I do think the longing I felt Saturday morning to be with Julia helped me focus and pray and work for Precious.  Still hoping.



Then, up the hill to RVA, for the Sports Tournament/Senior Store Saturday.  And as I reached the top, I had the idea to take pictures of people wishing Julia happy birthday and post them to her on facebook. Liana Masso is way more artistic than I, and agreed to make a sign.  So as we watched games and stood in line for food and talked to friends, I snapped a dozen or more photos of people who knew Julia, greeting and smiling.  The edge of wistfulness was blunted by being in a place where people know Julia and care about her, where they can light up with the reminder that it is her birthday, and the opportunity to participate.


Our evening ended with dinner at our good friends' the Massos, because they are like family, and know it is hard to be away from a daughter on her birthday.  From experience.  When their daughter was with us.  Full circle now, they pulled us in for a cake and calling and passing the phone around the table to all say happy birthday to Julia.

The boys won the tournament.  Jack scored a key goal in one of their closest games (he had promised Julia to score one for her!) and assisted the second goal that won that game, as well as the overtime golden goal that won the semifinals.  He played with skill and passion.  I love seeing him use his speed and strength to battle it out, and the way he passes into the center and gives his team mates the opportunity to score.

But today the wistfulness is edging out the thankfulness.  Partly from the realization that I don't know where we will be on future birthdays, but we are unlikely to be around as many people who know our kids as we are here.  Part of what binds us to Kijabe and RVA is that it was a home for them (though never for the six of us together), that when I walk around on October 4th I run into LOTS of people who know and love Julia.  And while we have a long way to go until our HMA (furlough), part of what will make it hard to leave will be leaving behind people who share in our love and parenting.

So it's Happy 18th to Julia, and THANKS to our friends especially the Massos and Harteminks, and PLEASE PRAY to those whose daughters are also PRECIOUS that this 3-month-old would wake up, and that we would take the vulnerability of love in stride, and keep walking this path.



Thursday, September 25, 2014

Thoughts on parenting, vaccines, sex, and the desert

We are the student health doctors and as such, we've had some emails this week about a controversial topic:  HPV (human palliomavirus) vaccines for early adolescents.  In Pediatrics they are considered routine adolescent anti-cancer vaccines (virtually all cervical cancers are caused by HPV).  For once there is a cancer that is completely preventable if a person is never infected with the HPV virus.  The rub comes when parents with very strong Christian beliefs assume that their child will never be infected, because he/she will never have a sexual encounter until their wedding day, and will marry someone who also remained celibate until that moment.  I fully believe that is healthy, and best.  And possible.

But far from a guarantee.  We live in a broken world.  Even Adam and Eve, who were created perfect and then parented directly by God and had daily intimate communication with Him, succumbed to the temptation to do the one thing they were forbidden.  Christians sin.  All of us.  Pride, gossip, laziness, cruelty.  And sometimes, being led away by passion to make a physical commitment beyond readiness for a full-life commitment.  There will be consequences emotionally and physically.  There will be grace, and healing.  But I would hope that if we could prevent one consequence, that of death by cancer in one's 30's, by a simple vaccine, we would do that.

Secondly, the broken world means that even if a particular kid is faithful and abstinent, she may be harmed by the sin of another.  Nice girls can be naive.  They can have something like valium slipped in a drink.  They can wake up to find themselves raped.  More than half of young adults in past decades ended up infected with HPV, so chances are pretty high that a rapist would transmit the disease.  Again, there is grace and healing, but in this situation we'd all opt for preventing AIDS or cancer if we could, wouldn't we?

Thirdly, even if the child walks down the wedding aisle having made perfect choices, and having been protected from all harm, there is a good chance his/her spouse will not have had the same advantages.  Some wonderful people become Christians later, after having made choices that left them with scars.  There is such beauty in that.  In fact the whole book of Hosea is about God asking one of His servants to marry, love, protect, redeem a former prostitute.  When your kid is 12, you have no idea what path God has for him/her in the decades to come. We are surrounded by a world where the Fall means that disease and death abound.

In this context I read with my team yesterday the story of Hagar and Ishmael.  Remember her weeping in the desert, thinking her son was going to die?  There she was, at the end of her resources, facing the worst thing imaginable for any of us as parents.  Helpless.  And what put her there was a mixture of her own choices (taunting Sarah), the sin of others against her (she didn't exactly choose to be a bondservant most likely, and having Abram's baby may not have been her choice either, let alone being sent into the desert), and the general brokeness of a world of deserts without water, of distance, heat, and exhaustion.  Yet at that moment, God hears, sees, comes.  He provides.  He rescues.  Even if she sinned and others sinned and the world is a mess, He still saves the boy from some of the consequences.  He does not add up and inflict upon us exactly what we deserve.  Because the deepest part of God's nature is love.  For us and for our children.  I find this extremely encouraging, that if God hears the prayerless despair of a foreign servant friendless and alone in the desert, He also knows how to provide for us and our children.

So, parents, I am opting for vaccination.  I truly hope none of my children need that extra margin of protection.  I hope they experience only true, faithful, exclusive love in their lives, and so do their spouses.  But if they, like Hagar and Ishmael, find themselves beat up by this world through their own choices, or the choices of others, I have the small comfort that cancer may not be one of the dozens of things that need healing.  And the large comfort that NOTHING can separate them from the God-who-sees.  That Love is suffusing the hot desert winds, and will provide and oasis.


Monday, September 15, 2014

Baby Hope

Just talked to R this morning, and she mentioned that she has named her baby "HOPE".  How perfect is that?  Rom 5:3-5.  Let this Hope not disappoint.