Monday, February 28, 2011
Sunday, February 27, 2011
Saturday, February 26, 2011
Wednesday, February 23, 2011
Saturday, February 19, 2011
Wednesday, February 16, 2011
Tuesday, February 15, 2011
Today Baby F went home, with a smiling mother. Not a tinge of yellow. Feeding well, and looking relatively normal, if you don't look too hard. No seizure medicines, no medicines at all. A grueling effort now recedes into the blur of hours long gone, and a delighted young woman, whose brush with bereavement came too close, holds a baby.
Today we got a final lab back on Baby A. He had been born in late November, and went home, at last, yesterday. I was only part of the latter half of his course, but it was enough to soberly acknowledge his escape. He was born as a premature speck to an HIV-positive mother. As if that weren't enough, he had dangerously immature lungs, and developed life-threatening meningitis, growing stool organisms from his brain linings. Not good. Three weeks of strong IV antibiotics and a small intracranial bleed later, he was still twitchy and volatile. One day it occurred to me from the dark recesses of memory that his spastic movements reminded me of some babies who reflux, whose acid-laden stomach contents boil back up into their esophagus. We tried some ulcer-calming type of medicines and positioning, and it did the trick. Slowly he emerged from his oxygen-dependence, and lost tubes, and gained flesh, and one day there he was, a little boy with a face and personality. When we discharged him, his mother (whose eventually fatal disease did not keep her from investing hour by hour in the survival of this son) simply said "I have no words to thank you, may God bless you." We prayed for A and his mom, and asked her to pray for us. So it was very sweet to get the news today that his HIV test was negative. He has escaped about four commonly fatal conditions already, and he's not even five pounds yet. That is mercy.
Those two departures made room for the next struggles. Baby H and Baby N, neighbors now in suffering. Baby H was born in a refugee camp for Somalians just inside the barren, distant border of northern Kenya. Only the problem was, where she should have had an open anus for passing stool, she had a dimple of intact skin. By the second or third day of life she was vomiting everything that could not pass through, and her mother got on a bus, alone, and took the two day trip to Kijabe, where she can't speak to any of us. We gesture a lot. This woman is a refugee mother-of-8, who just survived childbirth and a punishing journey, and sits now amongst strangers with a critically ill baby, which somehow amazes me. The surgeons saved the baby's life with a temporary colostomy. She has the most beautiful face. And her room-mate Baby N, faces a surgery tomorrow that she may or may not survive. She was born without skin or skull bone over most of the top of her head, only the linings which cover her brain. With a bandaged head she looks exotic, Nefrititi-ish, but beneath those wraps the dura membranes are darkening ominously. Her syndrome includes a whoppingly worrisome heart murmur and tiny malformed fingers and toes. But she is alert and otherwise lovely and feeding well, her mom's first baby. The surgeons tomorrow will try to stretch some scalp over her defect, and perhaps transfer grafts of flaps from other areas of her tiny body, bloody and technically challenging enough without the question of her heart's capacity.
This is Kijabe, a place that seems to draw in fragile, marginal, guarded-prognosis people. As Scott and I often say to each other, almost everyone we care for here would have been long dead in Bundibugyo. Instead, here, they are scooped up into the Kingdom, the mountain of the Lord that is populated by the scabby-scalped and jaundiced and spastic. Here they are treated with the honor of being important enough to warrant surgery and xrays and labs and effort. Here they encounter a few missionaries but mostly dedicated Kenyans, who are raising their own money for new projects, and providing their own administration, who are accessing the internet and pondering the possible. Bundibugyo in another fifty years? I hope so. Let us be patient.
Sunday, February 13, 2011
Thursday, February 10, 2011
IF ALL GOES WELL. That's a big IF. Baby F's first exchange had brought him from 40 to 32. An improvement, but atill in the severe panic range. I knew we'd have to do it again, so I didn't wait around, and made the plan first thing in the morning, hoping to be done by noon. Ha! By noon we had just received the donor blood for exchange. I still thought, foolishly, that I could make it to the latter part of an afternoon birthday party for one of our missionary colleagues, and hopefully even a planned late afternoon walk and talk with another mom. These were to be my first really social events and I was looking forward to them. However, what followed, from 12:30 to 8:30 pm, was eight hours of a bloody mess.
The line was the main problem. Newborns have the blessing of an umbilicus, and it is usually possible to put a steady, large IV line in the umbilical vein. The peds surgery team had done so the night before, a bit more difficult since the baby had been at home for a week, but done, so we were all set. But actually, we weren't. The promising umbilical catheter behaved erratically. You have to be able to pull blood out and then push other blood in, 20 cc at a time, in and out, about 25 or 30 times, until a half-litre or more of blood is exchanged. At every 5 minutes, it should take 2 to 3 hours. After the first hour we had barely done anything as we fiddled with the line, noted air bubbles, tried to change the connections, pondered a too-dark xray for placement, consulted surgery again, held up other catheters to figure out how long F's was and where it ended in his body. In short, we struggled. Eking out a few cc's of blood here, pushing in a few cc's there, always with the tenuous feeling that our access was about to close.
Baby F, with his sickly yellow skin, his stiff spastic body, his scarily pulling ribs as he tried to breathe, his oxygen tubing and IV's, his monitors beeping, did not protest. Even when at the six-plus hour mark we gave up on the line and jabbed his groin for a second IV. The difficulty of drawing from either line led to lots of small, 1 or 2 cc aliquots. Frothing blood, a dripping, slimy mess, aching back and legs, sweat in the steamy nursery, glaring lights, the blue bili-rubin lights shining in our way too, recording amounts and times, checking the baby. Who barely whimpered and never cried. Who had nothing to eat all day either, who was basically tied down to the treatment table.
I confess, here and now, I did not have a noble attitude. I knew I had to stay until the bitter end, this was my problem on my service. I'm so thankful for the partnership of a young Indian doctor who is working at Kijabe for a few months, and for the nurses who recorded the struggle and checked the vital signs. But as the day wore on into evening and night, no lunch, no dinner, no bday party, no walk, no break, I was getting more and more frustrated. Because in my heart I was thinking: this is pointless. This baby is already devastated. Are we really doing any good?
We had hoped to get the level below 25, and the next morning as I waited for the results, I was determined NOT to go through this process again. The results: 19. Better than we had hoped, probably because the whole process took so LONG there was more equilibration and effect. Next day: 13, then 8, then 5, then 3. With no further therapy. And baby F became less stiff. Without the lines and oxygen and dripping blood, he looked, well, baby-ish. Today he was breast-feeding, noisily and hungrily. He's off all his seizure medications, and not convulsing. He is starting to look like he will survive, he will leave this nursery soon. I don't think he'll emerge unscathed. His hearing is likely affected, and he may look like a cerebral palsy kind of kid. But the newborn brain is pretty amazingly adaptable. So only God knows.
Which is the point. Only God knows. And God was listening to one of the older ladies who accompanies her doctor-husband here every year, and then spends her time praying and ministering to others. She had come by our house and found me gone that first night, and when she didn't find me and heard about baby F, she decided to pray for him. And I wondered how the bilirubin levels had continued to fall so dramatically! Baby F was PRAYED for.
The cross was a bloody, curative mess too. For people like me, who, compared to Jesus, do not seem to hold much promise. Aching hours of effort, a sanginous sacrifice. No stinginess from God, no weighing of the prognosis, no withholding of the costliest and best. Let me plunge into the bloody messy world like Jesus, and let that effort bring life.
Monday, February 07, 2011
Saturday, February 05, 2011
Some of you may remember the story of a young Ugandan who became a Christian as a result of listening to Robert Carr and Alan Lee fight during a car ride over the Rwenzoris – and then repent to each other for how they had sinned against one another. That young man was Isingoma Edward. Isingoma (his name means "the first of twins") has been a colleague and partner to WHM-Uganda missionaries for 25 years. He's got tremendous leadership gifts and the requisite Masters degree for the Head Teacher job. When we offered Isingoma the job last week, his response was this: "I am ready and willing to do anything in my power to serve World Harvest Mission and Christ School." He has a fervent passion for knowing the LORD and making Him known. He firmly grasps the Vision Statement of CSB:
An academically excellent senior secondary boarding school
producing servant leaders
for the good of Bundibugyo and God's glory.
Please continue to pray for Christ School, for Isingoma as its new Head Teacher, and for Travis and Amy as they lead the Team and the school.
Wednesday, February 02, 2011
Scott here. Being “on-call” is part of the life of a physician. Last night, at Kijabe Hospital I was “on” for Medicine. Thankfully, though, because of our age and experience Jennifer and I are never the “first call” – that burden falls to our Kenyan Medical Interns. My front line warrior last night was Issac, a quiet diligent and quite competent young doctor. He called about 10pm last night for help. He was trying to clear the Outpatient Department so he could get some sleep. A dozen or so patients who had clocked into the OPD in the midafternoon were still waiting – and their patience was wearing thin.
So, braving the howling gales and pitch dark, I trudged over to Outpatient. I found a sleepy group of patients waiting for their turn to tell their stories to a doctor. None were critically ill, but obviously all felt ill enough to wait for hours to get an evaluation – and hoped for a cure. I sent a 6 year old for an elbow x-ray, admitted a 50 year woman who was scheduled for elective thyroid surgery tomorrow…and then came to W., a 55 year old woman with an “something in her stomach”. This lady stated she had a mass in her abdomen which had been moving around for the past FIVE YEARS. “Ma’am,” I said, “why have you decided to come to Kijabe Hospital TODAY – at 3pm in the afternoon – when you have been having this problem for FIVE YEARS?”
“Well, because my neighbor came to Kijabe and she got treated – and she’s better now,” she said.
“Where do you and your neighbor live?” I queried.
“Mombasa. I rode the bus from Mombasa early this morning.”
Yikes. That’s easily an 8 or 9 hour bus trip. This lady spent a considerable sum of her small savings, invested an entire day, and trekked halfway across the country, and ended up seeing me – hoping for a cure.
I’ve heard this type of complaint scores of times. “The worms are eating up my insides…the worms are moving around inside of me…there’s a stone growing up in this side of my belly…” Frankly, it’s a tough type of case to treat. Sometimes there is a diagnosis to be made; giardia, enlarged spleen from malaria, dysentery…and sometimes I can’t identify an explanation of the symptoms. In Bundibugyo, without any diagnostic tools, the latter was often the case. I began to feel a bit nervous – what if I can’t do anything for this lady? That will be horrible.
Well, I thoroughly examined her abdomen – no small challenge since there was about 6 inches of adipose tissue between my hands and her innards. I did detect a slight firmness and tenderness in her upper abdomen – so I decided to send her for an abdominal ultrasound, but that couldn’t be done until tomorrow.
“Ma’am, I want you to come back for ultrasound in the morning. Do you have anywhere to stay tonight? Do you know anyone around here?”
“No. I’ll just sleep here on this bench. I got no where to go.”
So, I handed her a requisition for the ultrasound – and prayed that somehow she could be satisfied – with her care, with the outcome, with whatever diagnosis she ended up with.
I don’t know what happened. But I do know that I need to have that kind of hope, that surety that somehow God can make things all right – and I need to have a similar willingness to sacrifice all that I have in order to allow Him to do so.
Tuesday, February 01, 2011
I bypass the nursery and ward and head straight to the newly constructed suite of operating theatres, where I change into clean clogs, mask, gown, hair-cover. There is the intern who called me, checking the warming bed and oxygen flow in the neonatal resuscitation room. I peek into the operating theatre next door, through the glass windows in the swinging doors, where the surgeon happens to be Scott. He let the on-call family physician know that one of his goals here at Kijabe is to become more proficient with C-sections, and at this moment he's well into what will be the second of three between 9 pm and 3 am. This woman, I hear, has severe pre-ecclampsia and gestational diabetes. She's been deteriorating all weekend and is now under general anesthesia in an attempt to save her life, and hopefully that of her 35-week (one month early) infant. No time to ask questions because I can see the smooth bloody purple curve of a head being pulled from her abdomen.
A few seconds later the baby is rushed into our room. I thought I heard a whimper, but when the scrub nurse deposits the infant on the warmer, I see no signs of life. He is limp. Not even a gasp of breath. The intern and I rub his back, talking to him, willing him to breathe baby breathe. We dry his slippery brown body and hold the oxygen near his face. I feel for a pulse, and feel nothing. Start bagging, I tell the intern. NOW. The intern places a mask over the baby's face attached to oxygen, and very effectively delivers breaths, a little too fast but that's to be expected in the stress of the situation. I have my stethoscope out, hear good air entry, and now the beginnings of a heartbeat. As we reach the one minute mark, we pause and dry and rub again, trying to wake him up. Apgar 5 out of 10, he's pink and has a good heart rate thanks to the initial resuscitation. Bag another half a minute. Now his arms are moving, he grimaces, and weakly cries. We change for dry cloths, blowing a little oxygen by his face as he now decides to make the transition to life. We check over his whole body now that we aren't focused on the basics of survival. He's beautiful.
Mom is still unconscious and we're not so confident of this baby's strength, so we decide to take him back to the nursery with us. I gather him up in my arms wrapped in surgical cloths, warm and solid, and walk him through the sleeping hospital into the blue glow and steamy warmth of the NICU. Since his mom was diabetic and he's premature we have to watch his blood glucose level, and put him on IV fluids and oxygen and a monitor for a day. But today he's fine, and now I think as a mom more than a doctor and convince the nursery team (who would rather have him attached to tubes and under their eyes) to let him go back to the maternity ward and bunk with his mom, so he can start breast feeding. She's slowly improving, delivery being the cure for toxemia. In the afternoon I check back and am relieved to know he's fine.
An hour or two for the mom, a few minutes for the baby, the difference between life and death. The availability of a safe and competent C-section for her, the immediate response of warmth and a kick-start of breathing for him, and now the prospect of continued life instead of two burials. Most hours aren't so clearly beneficial to anyone, so it is something to savor, to witness pink warm life creeping into an infant body. Of course in the case of Kijabe, this all would have happened without us, there are many doctors here. It just happened to be on our watch this time.
Here is my secret: I love being on call. I like the quietness of the hospital at night, the focus of only one operation, one baby in need, one admission. The thinning of the crowd, the direct contact with one family or one intern. The friendliness of the nurses away from the pressures of the day. The slipping back out into the night when all is settled, the brisk walk back to a sleeping house. The momentary assurance, that's why we're here.