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Friday, October 24, 2014

On labor and love


Sometimes one can wonder why babies come into this world at such a cost. There's a lot of loss, as untold numbers of conceptions end in miscarriage (some think 30% or more). There's grief, disappointment, dashed hope, tenuous chances.  Then when things go well, it is still far from simple.  There's what is euphemistically referred to as discomfort.  There's blood and pain and the absolute terror that the contractions will never end and one's body will split apart. There's indignity and soreness and inconvenience and bone-weary-blury-tiredness and dependence.  There's all those days of seeing one's mistakes with retrospective clarity.

It's been a few years since I last gave birth (16, actually) but I regularly stand at the very bed where I delivered a son, and hold the hands of moms doing the very same thing.  Tuesday night was a meconium fest.  Stressed babies, stressed moms, stressed staff.  One mom tried to bite me.  I know she didn't mean it.  It's just that hard.  I often stand there trying to fill their minds with encouragement and truth, trying to be a human presence in a rough spot.  Her baby was cone-headed and limp, breathless and blue.  I intubated his trachea and sucked out the green fluids, gave him breaths and dried him vigorously.  We took him to nursery to be sure he was OK.  He was.  Two hours later he was dressed up in his nice warm little outfit and hanging out with his mom, who was already probably forgetting the way she had been screaming.

It was a long night, followed by normal work the next day, and the usual flow of the week.  Things like praying with our department, fielding phone calls about transfer patients, examining labs, running rounds, researching protocols, organizing job charts and reviews, responding to anxious parents, looking at rashes.  So when I walked through the gates again at 8 Thursday morning, I was probably still a little tired.  I was barely in the door when my phone rang, nurses asking me to come to the neurosurgery ward for a resuscitation.  I briefly tried to think if this was someone else's job, but no, it was mine. So I excused myself from the patient I had started to see and hustled over to help.

Baby A had been discharged the day before, after repair of his meningomyelocele (spina bifida). We are a world epicenter for spina bifida care.  Our ward is packed with little bodies with big heads.  Babies who have spindly limbs and too many infections.  The excellent neurosurgical clinical officer had already taken several appropriate steps of evaluation and treatment.  We had a line, gave fluids, bagged breaths, checked blood, listened and examined.  His breathing was shallow and erratic.  I admit my first thought was:  does this baby really have a prognosis that justifies intensive care?  I confess some compassion fatigue, but it's a legitimate question in a place with very limited resources.  The surgeons who were his primary team popped their heads in the resus room.  Yes, they said.  So be it.  We moved him to the HDU until ICU could be prepared, gathered our resources, and I put a tube through his mouth and into his airway, and took over his breathing.  We got antibiotics, stat.  We got warm bags of IV fluid to pack around his cold little body.  We got a cot-warmer on wheels, portable oxygen, and headed to ICU. Xrays, tests, ventilator, monitors.

Later as I was signing him out to my colleague, I implored for all-out care.  Baby A had responded to our interventions.  I was hopeful.

And I was invested. Because he was no longer just another spina bifida baby.  Those hours of intensely working on him created a bond.

Which is why I think babies are so much work.  They need a bonded, invested human being, and we are wired such that the more we pour in, the more we care.  Where your treasure is, there your heart will be also.


This is precious, being discharged yesterday.  I spent countless hours on her survival, which makes me care a lot that she was prayed for by so many people, though nothing compared to her mom's happiness.  She still has a long road of brain recovery, but we are hopeful and grateful.  Keep praying.

I've been reading a book by our very own Serge missionary and friend, Barbara Bancroft.

The exhausting nature of ministry drags us down and steals our faith. Just one phone call, email, or Facebook posting can ruin our day.  Serving people means that we are invested in them; we have intertwined our lives with theirs.  Thus, we are vulnerable.  Paul's prayer for the Ephesians points us to a source of joy and power that is not connected to our ministry.  Rather, it is connected to the character of our Father and the love of our Savior. . . . 

Thus the mystery of the labor of love.  Need calls to our hearts.  We are intertwined with fragile babies, not to mention distant kids who sometimes have a bad day, a failing grade, a broken relationship, a sore throat, a busted knee, a dashed dream.  Thus, we are vulnerable, as Barbara says.  Our hearts are in places where outcomes are sometimes tragic.  So our very survival depends on being re-filled with God's spirit, being renewed with the assurance of His love.  The answer isn't to stop caring about spina bifida or college applications.  The answer is to keep allowing our lives to intertwine with the very things that can break our hearts, while depending on the unstoppable and inexhaustible resources of Heaven.   Sometimes these precious ones will revive, survive, be glorious.  Sometimes they will not.  But either way I want to care, all-out.  And I want to believe God is present.




Open Letter: Post-Care for Ebola-Zone workers

Dear New York-
We are deeply grieved with all of you that Dr. Spencer, an Emergency Medicine Fellow in training in NYC who volunteered to work with ebola patients in Guinea, has fallen ill.  We pray that he will fully recover, and that no secondary cases will arise.

Some thoughts:
1.  Dr. Spencer is unlikely to have infected anyone.  NO ONE became ill from Mr. Duncan's initial visit to the hospital in TX, when he had mild symptoms. Ebola becomes contagious after the patient is symptomatic.  Decontaminating cruise ships and planes because they were touched by exposed people, in some cases prior to illness and in other cases without any illness at all ever, may not be an effective use of resources.  Following up random subway and bowling alley strangers may not be either.

2.  Post-ebola-care workers need a place to go, because of the climate of hysteria.  In spite of calm pronouncements that people are not infectious until they are sick, panic ensues. Then politically someone has to take action which is justified by the phrase "out of an abundance of caution".  It would be much less expensive to provide a designated 21-day incubation camp near an excellent hospital prepared to care for any post-service cases that arise.  Note that SIM quietly set up an RV camp for potentially exposed people returning from Liberia, kept them quarantined for 21 days, no one got sick, and all was well.   The ebola czar would spend less money designating a place for medical workers to recuperate/isolate/incubate and be well cared-for, than in spending money reacting to the panic that arises with any new infection.  Even though they are not putting people in danger going to the grocery store while well, it is true that human beings facing potentially fatal diseases have such strong denial mechanisms they may block out their initial symptoms.  So if we're going to pour resources into "an abundance of caution", let's put them in making life better for the brave souls who volunteer rather than persecuting and second-guessing them after they return. Perhaps the "sluggishness" reported by the press that preceded Dr. Spencer's emergency trip with a 103-degree fever should have been recognized as a prodrome, but anyone who is recovering from a stressful stint of work, jet lag, and culture shock, can feel sluggish.

3.  Not everyone who returns from West Africa is in the same risk category.  Ebola is transmitted by close contact with sick people.  That means family members, health care workers, and burial teams.  Those are the people who need to be followed up, and need sympathy and care.

4.  Remember the numbers.  Liberia, Guinea, and Sierra Leone are home to about 21 million people.  Ten thousand have been infected with ebola this year.  That is 0.05% or 1 in 2000 people. Horrible, tragic, and way too many, absolutely devastating to any country to lose that many people.  However, not all Africans, or West Africans, or even Liberians, etc. are potentially a danger to anyone.   There are 1,999 safely uninfected people living in those countries for every ONE person who is infected.  Amongst international travelers, only one random guy has become ill.  If 150 people a day travel from those three countries to the USA, that means in the 8 months of the epidemic 36,000 have come to the USA, with one sick.  Just keep that in in mind when setting budgets.

Bottom line:  Spend money and emotional energy and logistical support where it counts.  Send help to the affected countries, and take care of the family members, health care workers, and burial teams.  Prioritize creating safe places for those who volunteer needed care, so they are not hounded and stigmatized and blamed when they return.

Thanks,
A pair of docs

Thursday, October 23, 2014

A Clear Night

Not on-call or post-call.  No moon.  No clouds.
So, I went down to the Kijabe airstrip for some night photography of the Great Rift Valley with a photographer friend.
Spectacular.

"The heavens declare the glory of God,
and the sky above proclaims his handiwork..."
Psalm 19:1




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.