Last weekend, the first two days of October, and by the end of them I thought I might need the rest of the month to recover. There are call days, and there are call days. This one did not start off too badly, rounds were reasonably efficient, and I ran up the hill to the school to watch the boys play soccer. At the very moment that Caleb scored the opening goal of the match, my phone rang from the ICU asking me to come for a little neurosurgical baby who had "coded" on the floor and been temporarily revived and transferred up to intensive care. And that was pretty much the last free and happy moment of the weekend, and beyond. It all runs together now, but I will tell you a few stories.
Friday, October 07, 2011
Week in Review, part 2 - Challenges
Because life is always that way. A celebratory week can not just be savored, it has to be wrested from the thorns. From the Fall, the curse meant that we could live under the vine and fig tree, but only at the cost of the sweat of the brow. We could commemorate the joy of 15 years since bringing forth a particular child, but only in the context of mourning for others.
"Baby of Carolyn" lived her whole life in this week I'm reviewing. I was with her at the moment of her birth Saturday, and the moment of her death at 4:40 this morning. It all started when her mom was transferred into Kijabe from a smaller clinic, bleeding and leaking amniotic fluid, with a supposed 30-week pregnancy whose fetus measured smaller than that and with a dangerously falling heart rate. Her husband did not feel he could afford an emergency C-section or intensive care that might be needed for the baby, nor did he think the baby could survive, so they refused at first to sign consents. Which left Scott, on OB call, and me, on Paeds, standing in the labor room calling our medical director and executive director for ethical advice. Within a few minutes we got permission to insist on trying to save the baby, even if the hospital would be left with the bill. And within a few minutes after that Scott was extracting the baby girl surgically and I was coaching the intern through a resuscitation of her tiny limp blue not-even-gasping form. She began to breathe with help, pinked up, moved. She weighed 840 grams. Things were going as well as one could hope with such a distressed preemie until I intubated her for the first dose of surfactant, a soapy coating that preemies lack in their lungs. I put the tube in too far (easy to do in such tiny babies) so that it lodged in her right mainstem bronchus, and the intern assisting me gave the first few breaths with nervous vigor (also easy to do in this stressful situation). I was listening for breath sounds and watching the monitor, and neither looked good, and then I looked back down at the baby and nearly died of shock and dismay when I saw that I had given her such a severe pneumothorax that air tracked up and ballooned under the skin of her neck. I called our excellent anesthesia and surgical attendings for rescue, certain that I had killed the baby. It was a terrible hour, but they were able to place a chest tube and re-intubate and stabilize. I took her to the ICU (my second newly ventilated patient of the day). It was a long weekend with her, trying to keep the tube in place, following xrays, managing her fluids and tiny initial feedings, comforting her mom. And throughout the week, I had hope. Even when I happened to be the one who found her when her tube was out, who set her up on CPAP, and who ended up with her all night the last day of the struggle, when her heart was failing, her kidneys were failing, and we ultimately failed to save her life. On Saturday we had made the difficult decision to choose to go all out to give her a chance; by early Friday morning I had to make the much more difficult decision that we had done everything, and lost this battle. She had not taken a breath, moved, opened her eyes, made a drop of urine, all day, and even intubated and pushing in the breaths we could not get her saturations over 50% (normal is 90-100%). I stopped pushing and just put her back on oxygen and within two minutes she was dead. Her mom, achingly, thanked our team for trying, and said this was God's plan. Which is on a certain level true (Job says the Lord gives and the Lord takes away, blessed be the name of the Lord) but on another level is not, the cosmic struggle of good defeating evil means that babies like Carolyn's should linger into a full earthly life as eternity reaches down into their time.
It was a week for complex patients. Another baby, Samuel, was admitted over the weekend, transferred from another hospital where he'd been treated for pneumonia and had not really healed. HIs chest xray showed a discreet pulmonary mass, which by CT was later confirmed to be a rare congenital malformation. But that did not explain his extreme cyanosis; he was BLUE, and not that uncomfortable about it. So we got an echo in Nairobi which showed complete transposition of the main blood vessels leaving his heart. The blood which should flow to his lungs for oxygen flows to his body without much, and the blood which comes from his lungs just keeps going back there, two parallel independent loops. Needless to say he can't live long like this, but we hope that he'll qualify for surgery with a visiting team in November. I snapped his photo when his mom dressed him in a shirt labeled "Special" to remind us that his anatomy is not a mistake, God can take this problem and turn it to good.
Then there was the little girl with pneumonia who got worse and worse, as her infection spread into empyema, pus in the lining of her lungs. As well as the neurosurgical patient whose wound may have been infected with tetanus, she lies in constant spasm. Or the previously normal 8 year old boy whose week of fever and headache progressed to intractable seizures, whom I found admitted to our service with classic signs that his swelling brain was about to push down through his spinal cord into his neck. Another trip to the ICU. Or the infant we had sent home from the ICU a few weeks ago who returned with a big mass in his abdomen, which turned out to be his bladder, obstructed and damaging his kidneys. Or the HIV-exposed baby who was dwindling not from the infection but from hunger. Or the Maasai boy whose bizarre symptoms Mardi linked to sampling local mushrooms. And on and on.
Somewhere in there we also had a visit from a family from Germany, whose adoption of two Haitian children led them to establish a charitable foundation to fund projects for needy children. Though we had never met we bonded quickly over the stories of these patients, and it was a privilege to connect Simone with our Paeds ward chaplain Mercy. Mercy meets with and prays with every family on the ward, and through her loving care hundreds if not thousands of people have encountered Jesus in life-changing ways. She'll be able to help identify patients who truly can not pay even the nominal fees charged by Kijabe, and connect them to Simone's group in hopes of allowing more children with anomalies to access surgery, more families being crippled by expensive bills to break out of the cycle of poverty.
And I haven't even mentioned the national meeting for health in Kenya, which will have to have a separate post.
Birthdays, grandparents, donors, visits, meetings, severely ill patients, calls in the middle of the night, tubes and blood, oxygen and labs, cooking and more cooking, travel and hosting and plans, dishes and dirt, recoveries and tragedies. And not a lot of sleep. In the context of a minor cold and just not feeling very physically well myself, I think this was one of the most challenging weeks since we arrived in Kenya. I end it tonight, tired, and sad about Baby of Carolyn, relieved to take a weekend away from the craziness, and a bit drained of optimism.